Provider Demographics
NPI:1609952407
Name:BENTHAM, WAYNE DAVID LEROY (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:DAVID LEROY
Last Name:BENTHAM
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 1:3640 TALMAGE CIR STE 216
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110-7100
Mailing Address - Country:US
Mailing Address - Phone:952-431-5330
Mailing Address - Fax:951-431-5334
Practice Address - Street 1:3640 TALMAGE CIR STE 216
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55110-7100
Practice Address - Country:US
Practice Address - Phone:952-431-5330
Practice Address - Fax:952-431-5334
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62533-202084P0015X, 2084P0800X
MN684072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0186104OtherL&I
WA1609952407Medicaid
AR214692001Medicaid
MO1609952407Medicaid
276890OtherINTERNAL ID-MOTOR VEHICLE ID
WA8804185Medicare PIN
276890OtherINTERNAL ID-MOTOR VEHICLE ID
WA0186104OtherL&I