Provider Demographics
NPI:1790783165
Name:BENBOW, BRYAN DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:DOUGLAS
Last Name:BENBOW
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 1:4100 SUMMERHILL RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2732
Mailing Address - Country:US
Mailing Address - Phone:903-735-9802
Mailing Address - Fax:903-735-9806
Practice Address - Street 1:4100 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2732
Practice Address - Country:US
Practice Address - Phone:903-735-9802
Practice Address - Fax:903-735-9806
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8204207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127728001Medicaid
TX00T11FOtherBLUE CROSS
OK100152870AMedicaid
AR97055OtherBLUE CROSS
LA1490270Medicaid
TX035939003Medicaid
TX035939001Medicaid
TX035939003Medicaid
AR97055OtherBLUE CROSS
TX00T11FMedicare PIN
TX00T11FOtherBLUE CROSS