Provider Demographics
NPI:1912038597
Name:KO, BENNY SP (MD)
Entity Type:Individual
Prefix:
First Name:BENNY
Middle Name:SP
Last Name:KO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 637999
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-7999
Mailing Address - Country:US
Mailing Address - Phone:317-682-2030
Mailing Address - Fax:317-644-5060
Practice Address - Street 1:3660 GUION RD
Practice Address - Street 2:STE 101
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-1616
Practice Address - Country:US
Practice Address - Phone:317-920-7139
Practice Address - Fax:317-920-7229
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01024080A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00960535OtherRR MEDICARE
IN000000703094OtherANTHEM
IN100381260AMedicaid
IN100381260AMedicaid
INP00960535OtherRR MEDICARE