Provider Demographics
NPI:1942830971
Name:BURKETT, BENJAMIN MATTHEW (DPT)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:MATTHEW
Last Name:BURKETT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13932 LEXINGTON CIR S
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-4969
Mailing Address - Country:US
Mailing Address - Phone:765-366-7293
Mailing Address - Fax:
Practice Address - Street 1:13932 LEXINGTON CIR S
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-4969
Practice Address - Country:US
Practice Address - Phone:765-366-7293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013023A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist