Provider Demographics
NPI:1801888797
Name:BENSON, SUSAN RENE (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:RENE
Last Name:BENSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:650 SIGNAL HILL DRIVE EXT
Mailing Address - Street 2:PO BOX 1845
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4353
Mailing Address - Country:US
Mailing Address - Phone:704-696-2085
Mailing Address - Fax:704-660-0194
Practice Address - Street 1:128 MEDICAL PARK RD
Practice Address - Street 2:STE 200
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8578
Practice Address - Country:US
Practice Address - Phone:704-696-2085
Practice Address - Fax:704-660-0194
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2017-04-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC200200492208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89131JFMedicaid
NC89131JFMedicaid
NC2004310Medicare ID - Type Unspecified