Provider Demographics
NPI:1932310620
Name:PALOMBO, BENJAMIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:J
Last Name:PALOMBO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4806 WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5100
Mailing Address - Country:US
Mailing Address - Phone:337-296-4139
Mailing Address - Fax:888-443-7236
Practice Address - Street 1:4806 WEAVER RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5100
Practice Address - Country:US
Practice Address - Phone:888-443-7236
Practice Address - Fax:337-602-4904
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.204031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA02950Medicaid