Provider Demographics
NPI:1457326522
Name:OUBRE, BENTON MICHAEL
Entity Type:Individual
Prefix:
First Name:BENTON
Middle Name:MICHAEL
Last Name:OUBRE
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 1:9103 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-2440
Mailing Address - Country:US
Mailing Address - Phone:225-927-1190
Mailing Address - Fax:225-706-0160
Practice Address - Street 1:9103 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-2440
Practice Address - Country:US
Practice Address - Phone:225-927-1190
Practice Address - Fax:225-706-0160
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023818207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1485306Medicaid
LAG83673Medicare UPIN
LA1485306Medicaid