Provider Demographics
NPI:1912970773
Name:BENGTSON, TODD DAVID (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:DAVID
Last Name:BENGTSON
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:619 S FLEISHEL AVE
Practice Address - Street 2:STE 203
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2004
Practice Address - Country:US
Practice Address - Phone:903-525-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5139208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX020039690OtherMEDICARE RAILROAD
TX123704OtherCHIPS
TX752616977111OtherTRICARE
TX752616977053OtherTRICARE CHAMPUS
TX75-2616977-130OtherTRICARE
TX5076044OtherAETNA
TX123916203Medicaid
TX752616977083OtherTRICARE
TX88860GOtherBCBS
TX83Y708Medicare Oscar/Certification
TX752616977083OtherTRICARE
TX83Y708Medicare ID - Type Unspecified