Provider Demographics
NPI:1912443516
Name:PHILLIPS, BENJAMIN IV
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:PHILLIPS
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 NW 19TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-1605
Mailing Address - Country:US
Mailing Address - Phone:405-474-3162
Mailing Address - Fax:
Practice Address - Street 1:2015 NW 19TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-1605
Practice Address - Country:US
Practice Address - Phone:405-474-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist