Provider Demographics
NPI:1508862723
Name:SUPNET, BENJAMIN D (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:D
Last Name:SUPNET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7121 SPID
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-4941
Mailing Address - Country:US
Mailing Address - Phone:361-851-5000
Mailing Address - Fax:361-851-8053
Practice Address - Street 1:7121 SPID
Practice Address - Street 2:SUITE 302
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412-4941
Practice Address - Country:US
Practice Address - Phone:362-851-5000
Practice Address - Fax:361-851-8053
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXL3152207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146593201Medicaid
TX146593202Medicaid
TX146593201Medicaid
TX146593202Medicaid