Provider Demographics
NPI:1679952394
Name:MAYER, BENJAMIN A (DPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:A
Last Name:MAYER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11462 S UNION AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037
Mailing Address - Country:US
Mailing Address - Phone:918-417-2607
Mailing Address - Fax:918-417-2601
Practice Address - Street 1:11462 S UNION AVE
Practice Address - Street 2:SUITE E
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037
Practice Address - Country:US
Practice Address - Phone:918-417-2607
Practice Address - Fax:918-417-2601
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-27
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK4995225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200092180AMedicaid
OK200092180AMedicaid