Provider Demographics
NPI:1457666943
Name:ANTHONY, BENJAMIN PAUL (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:PAUL
Last Name:ANTHONY
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 W 16TH ST STE 3200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2280
Practice Address - Country:US
Practice Address - Phone:317-963-7082
Practice Address - Fax:317-963-7085
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10037187207Y00000X
IN01076968A207Y00000X
GA73698207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201371010Medicaid