Provider Demographics
NPI:1508992207
Name:BENGTSON, MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:BENGTSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2815 CATES AVE
Mailing Address - Street 2:CB 7304
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27695-0001
Mailing Address - Country:US
Mailing Address - Phone:919-515-2563
Mailing Address - Fax:919-513-1994
Practice Address - Street 1:2815 CATES AVE
Practice Address - Street 2:CB 7304
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27695-7304
Practice Address - Country:US
Practice Address - Phone:919-515-2563
Practice Address - Fax:919-513-1994
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC27540207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G36954Medicare UPIN