Provider Demographics
NPI:1306271838
Name:GUENTHER, BENJAMIN M (CO,LPO)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:M
Last Name:GUENTHER
Suffix:
Gender:M
Credentials:CO,LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2109
Mailing Address - Country:US
Mailing Address - Phone:903-592-5900
Mailing Address - Fax:903-592-6683
Practice Address - Street 1:1110 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2109
Practice Address - Country:US
Practice Address - Phone:903-592-5900
Practice Address - Fax:903-592-6683
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-03
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOI60339265222Z00000X
WAPS60452668224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOI60339265OtherSTATE LICENSE
WAPS60452668OtherPROSTHETIC LICENSE