Provider Demographics
NPI:1518999671
Name:BENTON, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
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 1:701 W 5TH ST
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-4206
Mailing Address - Country:US
Mailing Address - Phone:432-703-5200
Mailing Address - Fax:432-335-5316
Practice Address - Street 1:701 W 5TH ST
Practice Address - Street 2:ATTN: CREDENTIALING
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-4206
Practice Address - Country:US
Practice Address - Phone:432-703-5200
Practice Address - Fax:432-335-5316
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124570607Medicaid
NM31753515Medicaid
OK200061220 AMedicaid
OK200061220 AMedicaid
NM31753515Medicaid