Provider Demographics
NPI:1780666313
Name:BENTON, TODD A (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:A
Last Name:BENTON
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-3000
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:101 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-579-3000
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18965208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009932113Medicaid
MS06279075Medicaid
MS6116387OtherHEALTHSPRING
730-15546OtherBLUE CROSS OF AL
MS06279075Medicaid
AL009932113Medicaid
AL009932113Medicaid