Provider Demographics
NPI: | 1922108398 |
---|---|
Name: | BENSON, LARRY L (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | LARRY |
Middle Name: | L |
Last Name: | BENSON |
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: | 1115 BOULDERS PKWY |
Mailing Address - Street 2: | STE 200 |
Mailing Address - City: | NORTH CHESTERFIELD |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 23225-4067 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 804-560-5595 |
Mailing Address - Fax: | 804-560-9029 |
Practice Address - Street 1: | 7858 SHRADER RD |
Practice Address - Street 2: | |
Practice Address - City: | RICHMOND |
Practice Address - State: | VA |
Practice Address - Zip Code: | 23294-4222 |
Practice Address - Country: | US |
Practice Address - Phone: | 804-270-1305 |
Practice Address - Fax: | 804-273-9294 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-09-25 |
Last Update Date: | 2020-05-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 4301078205 | 207Q00000X |
VA | 0101242901 | 207QS0010X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207QS0010X | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VA | 1922108398 | Medicaid | |
VA | 1922108398 | Medicaid | |
VA | 017901C44 | Medicare PIN |