Provider Demographics
NPI:1942359005
Name:BENOIST, PATRICIA A (MD)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:A
Last Name:BENOIST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:A
Other - Last Name:EDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1337 S SAM HOUSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MO
Mailing Address - Zip Code:65483-2046
Mailing Address - Country:US
Mailing Address - Phone:417-967-5639
Mailing Address - Fax:417-967-5667
Practice Address - Street 1:1337 S SAM HOUSTON BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483-2046
Practice Address - Country:US
Practice Address - Phone:417-967-5639
Practice Address - Fax:417-967-5667
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063028A208000000X
MO2008016594208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00653959OtherRAILROAD MEDICARE
MO1942359005Medicaid
MO26D0889777OtherCLIA
AR172978001Medicaid
431560263OtherTRICARE WEST