Provider Demographics
NPI:1922218627
Name:BENSEN, ROBERT FORTIER (MD,ND,CCN)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:FORTIER
Last Name:BENSEN
Suffix:
Gender:M
Credentials:MD,ND,CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 SECURITY SQ
Mailing Address - Street 2:P. O. BOX 6055
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-6055
Mailing Address - Country:US
Mailing Address - Phone:228-897-2337
Mailing Address - Fax:228-897-2316
Practice Address - Street 1:445 SECURITY SQ
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1922
Practice Address - Country:US
Practice Address - Phone:228-897-2337
Practice Address - Fax:228-897-2316
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13456208VP0014X
LA018864208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5R343Medicare ID - Type Unspecified'OPTED OUT'
MSC71418Medicare UPIN