Provider Demographics
NPI:1891766580
Name:BENTON, THOMAS BB (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:BB
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:352-376-4542
Mailing Address - Fax:
Practice Address - Street 1:5612 NW 43RD ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32653-3332
Practice Address - Country:US
Practice Address - Phone:352-376-4542
Practice Address - Fax:352-376-4959
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53353208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOB157OtherMEDICARE HF
FL048463600Medicaid
FL048463600Medicaid