Provider Demographics
NPI:1932648920
Name:DRAKE, BENJAMIN MATTHEW
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:MATTHEW
Last Name:DRAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 HARDY ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1308
Mailing Address - Country:US
Mailing Address - Phone:160-129-6396
Mailing Address - Fax:
Practice Address - Street 1:121 N 20TH ST STE 6
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5454
Practice Address - Country:US
Practice Address - Phone:347-493-3853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-23
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2304207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program