Provider Demographics
NPI:1720154529
Name:JAIME C BENTON MD PA
Entity Type:Organization
Organization Name:JAIME C BENTON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRIMARY CARE PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:C
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:936-825-6444
Mailing Address - Street 1:500 E WASHINGTON
Mailing Address - Street 2:
Mailing Address - City:NAVASOTA
Mailing Address - State:TX
Mailing Address - Zip Code:77868-3002
Mailing Address - Country:US
Mailing Address - Phone:936-825-6444
Mailing Address - Fax:936-825-3340
Practice Address - Street 1:500 E WASHINGTON
Practice Address - Street 2:
Practice Address - City:NAVASOTA
Practice Address - State:TX
Practice Address - Zip Code:77868-3002
Practice Address - Country:US
Practice Address - Phone:936-825-6444
Practice Address - Fax:936-825-3340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0619207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM0619OtherPHYSICIAN PERMIT
TXM0619OtherPHYSICIAN PERMIT
H89908Medicare UPIN