Provider Demographics
NPI:1457557548
Name:MISSICK, BENJAMIN JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JAMES
Last Name:MISSICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:5815 BLAKENEY PARK DR
Practice Address - Street 2:SUITE 200B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-5731
Practice Address - Country:US
Practice Address - Phone:704-316-5080
Practice Address - Fax:704-316-5085
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC201001144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1683Medicaid
NC5915631Medicaid
NC5915631Medicaid