Provider Demographics
NPI:1972031011
Name:BENSON, GEORGE (DO)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:BENSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 BERGQUIST DR STE 1
Mailing Address - Street 2:
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236-9908
Mailing Address - Country:US
Mailing Address - Phone:916-747-0546
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR STE 1
Practice Address - Street 2:
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-292-5848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102205479208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program