Provider Demographics
NPI:1730281619
Name:BENTON, DOUGLAS J (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:J
Last Name:BENTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:G-6092 FENTON RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507
Mailing Address - Country:US
Mailing Address - Phone:810-239-4697
Mailing Address - Fax:810-239-4553
Practice Address - Street 1:6092 FENTON RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-4761
Practice Address - Country:US
Practice Address - Phone:810-239-4697
Practice Address - Fax:810-239-4553
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008533207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3235403Medicaid
MIM23560009Medicare PIN
MI3235403Medicaid