Provider Demographics
NPI:1821116021
Name:BENTON, JOHN WEBSTER (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WEBSTER
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 1:1600 UNIVERSITY AVENUE WEST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-379-2772
Mailing Address - Fax:651-379-2774
Practice Address - Street 1:1600 UNIVERSITY AVENUE WEST
Practice Address - Street 2:SUITE 306
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-379-2772
Practice Address - Fax:651-379-2774
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN18127207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3464Medicare ID - Type Unspecified
A94037Medicare UPIN