Provider Demographics
NPI:1326085051
Name:BENTON, MARY BETH (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:BENTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:402 KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6626
Practice Address - Country:US
Practice Address - Phone:573-499-6084
Practice Address - Fax:573-499-6088
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR2H46207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6642OtherBLUE SHIELD
MO6642OtherBLUE CHOICE
MO126944OtherHEALTHLINK
MO704051OtherUNITED HEALTHCARE
MO202817706Medicaid
MO2086348001OtherKANSAS MEDICAID
MO160049525Medicare PIN
MO321010635Medicare PIN
MO202817706Medicaid
MO969235236Medicare PIN