Provider Demographics
NPI:1699851923
Name:TITTLE, BEN J (MD)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:J
Last Name:TITTLE
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 1:10743 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230
Mailing Address - Country:US
Mailing Address - Phone:214-905-5075
Mailing Address - Fax:214-905-0903
Practice Address - Street 1:10743 PRESTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230
Practice Address - Country:US
Practice Address - Phone:214-905-5075
Practice Address - Fax:214-905-0903
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMDF 27352086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
4295465OtherAETNA
E21797Medicare UPIN
00F71JMedicare ID - Type Unspecified