Provider Demographics
NPI:1922063510
Name:FORE, BENJAMIN BAKER (DO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BAKER
Last Name:FORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 15TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401
Mailing Address - Country:US
Mailing Address - Phone:580-223-3737
Mailing Address - Fax:580-223-4801
Practice Address - Street 1:1005 15TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1810
Practice Address - Country:US
Practice Address - Phone:580-223-4800
Practice Address - Fax:580-223-4801
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2273208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2273OtherOKLAHOMA LICENSE
OK2273OtherOKLAHOMA LICENSE
OK2273OtherOKLAHOMA LICENSE