Provider Demographics
NPI:1962497305
Name:PHILLIPS, BENNY POTHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNY
Middle Name:POTHEN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3621 22ND ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1301
Mailing Address - Country:US
Mailing Address - Phone:806-796-1317
Mailing Address - Fax:806-796-0426
Practice Address - Street 1:3621 22ND ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1301
Practice Address - Country:US
Practice Address - Phone:806-796-1317
Practice Address - Fax:806-796-0426
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2851207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84141NOtherBLUE CROSS BLUE SHIELD
TX8062N0Medicare ID - Type Unspecified
TXC20487Medicare UPIN