Provider Demographics
NPI:1417405176
Name:MCLEOD, BENJAMIN L (NP)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:L
Last Name:MCLEOD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2317
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2317
Mailing Address - Country:US
Mailing Address - Phone:229-890-5305
Mailing Address - Fax:229-890-5307
Practice Address - Street 1:115 31ST AVE SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6771
Practice Address - Country:US
Practice Address - Phone:229-890-5305
Practice Address - Fax:229-890-5307
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN218215363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003180779BMedicaid