Provider Demographics
NPI:1811375082
Name:LACROSSE, BENJAMIN N (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:N
Last Name:LACROSSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-3306
Mailing Address - Country:US
Mailing Address - Phone:605-665-7841
Mailing Address - Fax:605-665-8337
Practice Address - Street 1:3901 W NORFOLK AVE STE R
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-4405
Practice Address - Country:US
Practice Address - Phone:605-665-7841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.0672402085R0202X, 208D00000X
390200000X
NE309322085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program