Provider Demographics
NPI:1679905756
Name:BENTON MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:BENTON MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:ZANDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-798-4539
Mailing Address - Street 1:PO BOX 52364
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-2364
Mailing Address - Country:US
Mailing Address - Phone:318-798-4664
Mailing Address - Fax:318-798-4457
Practice Address - Street 1:188 BURT BLVD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:LA
Practice Address - Zip Code:71006-4900
Practice Address - Country:US
Practice Address - Phone:318-798-4539
Practice Address - Fax:318-798-4601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09509R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty