Provider Demographics
NPI:1952387136
Name:BENTON, SUSAN D (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:D
Last Name:BENTON
Suffix:
Gender:F
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 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:12222 MERIT DR STE 600
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-3294
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7891207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128482010Medicaid
TX128482002Medicaid
TX8EH106OtherBCBS
TX8EH106OtherBCBS
TX128482010Medicaid
TX128482002Medicaid
TX339316YK6UMedicare PIN
TX89023KMedicare PIN
TX8L19057Medicare PIN
TXTXB106970Medicare PIN
TX128482002Medicaid
TX83872KOtherBCBS
TX050065941OtherRAILROAD
TX128482007OtherMEDICAID CSHCN