Provider Demographics
NPI:1720231921
Name:TIPTION, BENJAMIN KING (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:KING
Last Name:TIPTION
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 1:12520 PANASOFFKEE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-4755
Mailing Address - Country:US
Mailing Address - Phone:239-652-4140
Mailing Address - Fax:
Practice Address - Street 1:12520 PANASOFFKEE DR
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-4755
Practice Address - Country:US
Practice Address - Phone:239-652-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0034201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL039261800Medicaid
FLD58791Medicare UPIN