Provider Demographics
NPI:1477545754
Name:BENTON, JOHN B (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:BENTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9203
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-9203
Mailing Address - Country:US
Mailing Address - Phone:502-895-9627
Mailing Address - Fax:502-895-8977
Practice Address - Street 1:3950 KRESGE WAY STE 308
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4637
Practice Address - Country:US
Practice Address - Phone:502-895-8911
Practice Address - Fax:502-895-8977
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41725208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200448900Medicaid
INP00049026OtherRAILROAD MEDICARE PROV#
KY000063095GOtherHUMANA
KY64117005Medicaid
IN000000300382OtherANTHEM PROV#
KY000000548736OtherANTHEM
352154103OtherUNITED HEALTHCARE PROV
IN200448900Medicaid
IN185790CMedicare PIN
IN201550KMedicare PIN
KY00162047Medicare PIN