Provider Demographics
NPI:1720144637
Name:AVERY-BENJAMIN, CAUDREAN L (MD)
Entity Type:Individual
Prefix:
First Name:CAUDREAN
Middle Name:L
Last Name:AVERY-BENJAMIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAUDREAN
Other - Middle Name:L
Other - Last Name:AVERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
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:704-377-5675
Mailing Address - Fax:704-335-8163
Practice Address - Street 1:1918 RANDOLPH RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1100
Practice Address - Country:US
Practice Address - Phone:704-377-5675
Practice Address - Fax:704-335-8163
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430442207V00000X
NC200800028207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910315Medicaid
NC2008-00028OtherNC STATE MEDICAL BOARD
NC1720144637Medicare PIN