Provider Demographics
NPI:1629303904
Name:BENHAM, KIMBERLY (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BENHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:IRVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1329
Mailing Address - Country:US
Mailing Address - Phone:812-353-3087
Mailing Address - Fax:
Practice Address - Street 1:601 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403
Practice Address - Country:US
Practice Address - Phone:812-353-9515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.003167390200000X
IN02004082A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program