Provider Demographics
NPI:1255352787
Name:THEBAUT, BEN (MD)
Entity type:Individual
Prefix:DR
First Name:BEN
Middle Name:
Last Name:THEBAUT
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 11
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33468-0011
Mailing Address - Country:US
Mailing Address - Phone:561-748-2889
Mailing Address - Fax:561-748-1523
Practice Address - Street 1:2580 METROCENTRE BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3100
Practice Address - Country:US
Practice Address - Phone:561-684-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME20057207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
50611ZMedicare PIN
D62688Medicare UPIN