Provider Demographics
NPI:1821193772
Name:BLOUNT, BENROE W (MD)
Entity type:Individual
Prefix:
First Name:BENROE
Middle Name:W
Last Name:BLOUNT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5742
Mailing Address - Country:US
Mailing Address - Phone:305-831-4761
Mailing Address - Fax:305-831-4761
Practice Address - Street 1:206 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-4902
Practice Address - Country:US
Practice Address - Phone:863-209-7003
Practice Address - Fax:863-284-3083
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME123575207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF52984Medicare UPIN
TX8L19996Medicare PIN