Provider Demographics
NPI:1336450089
Name:SELBO, BENJAMIN R (D PT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:R
Last Name:SELBO
Suffix:
Gender:M
Credentials:D PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5000 ELDORADO PKWY STE 430
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-8608
Mailing Address - Country:US
Mailing Address - Phone:214-436-4606
Mailing Address - Fax:214-436-4794
Practice Address - Street 1:5000 ELDORADO PKWY STE 430
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-8608
Practice Address - Country:US
Practice Address - Phone:214-436-4606
Practice Address - Fax:214-436-4794
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1197795208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00609TMedicare PIN