Provider Demographics
NPI:1972598704
Name:BENHAM, SEAN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:THOMAS
Last Name:BENHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-0997
Mailing Address - Country:US
Mailing Address - Phone:920-482-0575
Mailing Address - Fax:920-482-0579
Practice Address - Street 1:1765 N 18TH ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54221-0997
Practice Address - Country:US
Practice Address - Phone:920-482-0575
Practice Address - Fax:920-482-0579
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33608020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
043684279011OtherBLUE CROSS BLUE SHIELD
WI31847300Medicaid
043684279011OtherBLUE CROSS BLUE SHIELD