Provider Demographics
NPI:1205054301
Name:DUBOIS, BENJAMIN CALEB (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:CALEB
Last Name:DUBOIS
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 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:1920 GALLERIA OAKS DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-4619
Practice Address - Country:US
Practice Address - Phone:903-792-6114
Practice Address - Fax:903-792-4266
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9202208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200449090AMedicaid
LA2443666Medicaid
TX337957001Medicaid