Provider Demographics
NPI:1760454078
Name:BENBOW, GREGORY ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLEN
Last Name:BENBOW
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:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-0388
Mailing Address - Country:US
Mailing Address - Phone:540-932-5162
Mailing Address - Fax:540-932-5875
Practice Address - Street 1:78 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2332
Practice Address - Country:US
Practice Address - Phone:540-932-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102037018207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005880351Medicaid
WV3810015628Medicaid
VA1760454078Medicaid
VA236392OtherBLUE SHIELD
VA00Y095E02Medicare PIN
VA236392OtherBLUE SHIELD
VA1760454078Medicaid
VA000179V67Medicare PIN