Provider Demographics
NPI:1265404065
Name:PHEN, BENJAMIN YAINTHANG (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:YAINTHANG
Last Name:PHEN
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 1:3410 PRESIDENT GEORGE BUSH TPKE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6629
Mailing Address - Country:US
Mailing Address - Phone:800-218-8989
Mailing Address - Fax:888-635-3573
Practice Address - Street 1:3410 PRESIDENT GEORGE BUSH TPKE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75287-6629
Practice Address - Country:US
Practice Address - Phone:305-266-2929
Practice Address - Fax:888-635-3573
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76136207Q00000X
TXT3683207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254655800Medicaid
FL43890ZMedicare PIN
FL0471260004Medicare NSC
G77348Medicare UPIN