Provider Demographics
NPI:1386796381
Name:LAMAR MEDICAL ASSOC PC
Entity type:Organization
Organization Name:LAMAR MEDICAL ASSOC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-336-9068
Mailing Address - Street 1:200 KENDALL DR STE 3
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:CO
Mailing Address - Zip Code:81052-3940
Mailing Address - Country:US
Mailing Address - Phone:719-336-9068
Mailing Address - Fax:719-336-3202
Practice Address - Street 1:200 KENDALL DR STE 3
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052-3940
Practice Address - Country:US
Practice Address - Phone:719-336-9068
Practice Address - Fax:719-336-3202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR22392207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01223924Medicaid
COLA08601OtherANTHEM BLUE CROSS