Provider Demographics
NPI:1891774675
Name:BENTON, ROLAND E (MD)
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:E
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 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-8681
Mailing Address - Fax:740-353-7900
Practice Address - Street 1:1005 E RING RD
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-9610
Practice Address - Country:US
Practice Address - Phone:740-534-9830
Practice Address - Fax:740-534-9832
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077695207Q00000X
OH077695207R00000X
OH35.077695207R00000X
KY35913207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000380359OtherANTHEM BCBS
WV1801701000Medicaid
KY64022619Medicaid
KY000000598423OtherANTHEM BCBS
OH2190276Medicaid
OH4028572Medicare PIN
KY64022619Medicaid
KY930099031Medicare PIN
KY0931015Medicare PIN
KYP00296977Medicare PIN
OH4028574Medicare PIN