Provider Demographics
NPI:1336140474
Name:COVINGTON, BENJAMIN WILSON IV (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:WILSON
Last Name:COVINGTON
Suffix:IV
Gender:M
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 26804
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76126-0804
Mailing Address - Country:US
Mailing Address - Phone:817-514-6193
Mailing Address - Fax:817-514-6947
Practice Address - Street 1:730 EUREKA ST
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-6546
Practice Address - Country:US
Practice Address - Phone:817-514-6193
Practice Address - Fax:817-514-6947
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5709207Q00000X, 207P00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170802601Medicaid
TXDC3066OtherRAILROAD MEDICARE
TXP00997727OtherRAILROAD
TX169989404Medicaid
TX8P2300OtherBLUE CROSS BLUE SHIELD
TX8C2573Medicare PIN
TXDC3066OtherRAILROAD MEDICARE
TX169989404Medicaid