Provider Demographics
NPI:1417913492
Name:BENSON, JONATHAN D
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:BENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR STE 310
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1733
Practice Address - Country:US
Practice Address - Phone:260-266-5230
Practice Address - Fax:260-266-5238
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01060622A207R00000X, 208000000X, 207RG0100X
TN44963207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4234546OtherBCBS
IN200529630Medicaid
TN4234546OtherBCBS
IN715530AZMedicare ID - Type Unspecified