Provider Demographics
NPI:1356301485
Name:INGRAM, BENJAMIN DERRICK (OD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DERRICK
Last Name:INGRAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4406 - A FOREST DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206
Mailing Address - Country:US
Mailing Address - Phone:803-782-7080
Mailing Address - Fax:803-744-0964
Practice Address - Street 1:4406-A FOREST DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206
Practice Address - Country:US
Practice Address - Phone:803-782-7080
Practice Address - Fax:803-744-0964
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1320152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD13206Medicaid
SCD13206Medicaid
SCAA05358225Medicare ID - Type Unspecified