Provider Demographics
NPI:1942235346
Name:MANNIX, BENJAMIN CARL JR (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:CARL
Last Name:MANNIX
Suffix:JR
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 1:1300 STATE ST
Mailing Address - Street 2:STE. 1-F
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3185
Mailing Address - Country:US
Mailing Address - Phone:219-362-6297
Mailing Address - Fax:
Practice Address - Street 1:1300 STATE ST
Practice Address - Street 2:STE. 1-F
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3185
Practice Address - Country:US
Practice Address - Phone:219-362-6297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031151207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN151020018OtherMEDICARE PTAN
IN000000836411OtherANTHEM BCBS
IN100335630Medicaid
IN100335630Medicaid