Provider Demographics
NPI:1316100423
Name:BREWSTER, BENJAMIN (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BREWSTER
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 1:2605 N LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2705 N LEBANON ST STE 365
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-8621
Practice Address - Country:US
Practice Address - Phone:765-485-8820
Practice Address - Fax:765-485-8829
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075061A208600000X
IN11014325A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201105310Medicaid
IN201105310Medicaid