Provider Demographics
NPI:1952491680
Name:BENTON, CHARLES F (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:F
Last Name:BENTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:PMG ISLETA
Practice Address - Street 2:3436 ISLETA BLVD SW
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105
Practice Address - Country:US
Practice Address - Phone:505-462-7777
Practice Address - Fax:505-462-7880
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2008-08-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM81-15207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28985Medicaid
347607401Medicare PIN
D35506Medicare UPIN