Provider Demographics
NPI:1013158088
Name:DEGATUR, BENJAMIN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:THOMAS
Last Name:DEGATUR
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 335
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-0335
Mailing Address - Country:US
Mailing Address - Phone:337-654-4501
Mailing Address - Fax:
Practice Address - Street 1:206 CHAMPAGNE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-3734
Practice Address - Country:US
Practice Address - Phone:337-332-3500
Practice Address - Fax:337-332-3200
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.205020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program