Provider Demographics
NPI:1578579793
Name:SO, PETER BENSON C (MD)
Entity Type:Individual
Prefix:
First Name:PETER BENSON
Middle Name:C
Last Name:SO
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR STE 440
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1672
Practice Address - Country:US
Practice Address - Phone:260-373-9935
Practice Address - Fax:260-373-9926
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057994A207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200455540Medicaid
INP00732005OtherRAILROAD MEDICARE
IN000000604550OtherANTHEM
INP00732005OtherRAILROAD MEDICARE
IN084510DMedicare ID - Type Unspecified
IN070860B8Medicare PIN