Provider Demographics
NPI:1295716587
Name:BENJAMIN, MARY EMELEE (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:EMELEE
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2495 SHREVEPORT HWY STE 104
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4044
Mailing Address - Country:US
Mailing Address - Phone:318-466-4522
Mailing Address - Fax:318-445-1663
Practice Address - Street 1:2495 SHREVEPORT HWY STE 104
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-466-4522
Practice Address - Fax:318-445-1663
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03853207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1113549Medicaid
LA1113549Medicaid
LAP45307Medicare UPIN