Provider Demographics
NPI:1245290972
Name:BENHAM, JERRY ALAN (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:ALAN
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 1:6600 FISH POND RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2581
Mailing Address - Country:US
Mailing Address - Phone:254-752-9638
Mailing Address - Fax:254-752-2201
Practice Address - Street 1:6600 FISH POND RD
Practice Address - Street 2:SUITE 201
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2581
Practice Address - Country:US
Practice Address - Phone:254-752-9638
Practice Address - Fax:254-752-2201
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0173207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102133902Medicaid
TXC13355Medicare UPIN
TX878184Medicare ID - Type Unspecified