Provider Demographics
NPI:1699774794
Name:OPHTHALMOLOGY ASSOCIATES OF BENTON, PLLC
Entity type:Organization
Organization Name:OPHTHALMOLOGY ASSOCIATES OF BENTON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE & CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DETHERAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-778-1113
Mailing Address - Street 1:3 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3728
Mailing Address - Country:US
Mailing Address - Phone:501-778-1113
Mailing Address - Fax:501-778-5391
Practice Address - Street 1:3 MEDICAL PARK DR
Practice Address - Street 2:SUITE 300
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3728
Practice Address - Country:US
Practice Address - Phone:501-778-1113
Practice Address - Fax:501-778-5391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7930174400000X
ARC7476174400000X
ARE-2274174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B790OtherBLUE CROSS BLUE SHIELD
AR140820002Medicaid
ARCI3712OtherRAILROAD MEDICARE
AR140820002Medicaid
AR4167140001Medicare NSC