Provider Demographics
NPI:1790948792
Name:WORTH, BENJAMIN WAIN (MPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:WAIN
Last Name:WORTH
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14547 N LANTANA BLVD
Mailing Address - Street 2:
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-3894
Mailing Address - Country:US
Mailing Address - Phone:417-459-0406
Mailing Address - Fax:
Practice Address - Street 1:7666 E 61ST ST STE 340
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-1148
Practice Address - Country:US
Practice Address - Phone:918-250-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist