Provider Demographics
NPI:1437151859
Name:BENTON, SCOTT ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ANTHONY
Last Name:BENTON
Suffix:
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-0115
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-0115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20296208000000X, 2080C0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1989690Medicaid
MS512I370103Medicare PIN
MS302I374199Medicare PIN