Provider Demographics
NPI:1386740082
Name:BENTON, OLIVER III (MD)
Entity type:Individual
Prefix:DR
First Name:OLIVER
Middle Name:
Last Name:BENTON
Suffix:III
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 1:1949 GUNBARREL RD STE 206
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-7133
Mailing Address - Country:US
Mailing Address - Phone:423-495-4349
Mailing Address - Fax:423-495-4934
Practice Address - Street 1:1300 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-2005
Practice Address - Country:US
Practice Address - Phone:423-756-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2019-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1467208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB58935Medicare UPIN
TN3019924Medicare ID - Type Unspecified