Provider Demographics
NPI:1629145198
Name:BENSON, MARK PALMER (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:PALMER
Last Name:BENSON
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 1:707 NORTH 7TH
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-233-4562
Mailing Address - Fax:208-234-4638
Practice Address - Street 1:707 NORTH 7TH
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-233-4562
Practice Address - Fax:208-234-4638
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCP9190OtherRAILROAD MEDICARE GRP #
ID29296OtherBLUE SHIELD GROUP NUMBER
ID0000100001648OtherBLUE SHIELD
ID002440600Medicaid
ID110042845OtherRR MEDICARE
ID36509OtherBLUE CROSS
ID88765OtherBLUE CROSS GROUP NUMBER
ID003608500Medicaid
ID110042845OtherRR MEDICARE
ID1111746Medicare ID - Type Unspecified
ID29296OtherBLUE SHIELD GROUP NUMBER