Provider Demographics
NPI:1861408015
Name:BENJAMIN, BONNA (MD)
Entity type:Individual
Prefix:
First Name:BONNA
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WALLACE BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1708
Mailing Address - Country:US
Mailing Address - Phone:806-468-4300
Mailing Address - Fax:806-468-4398
Practice Address - Street 1:1901 MEDI PARK DR
Practice Address - Street 2:STE 2051
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2169
Practice Address - Country:US
Practice Address - Phone:806-468-4300
Practice Address - Fax:806-468-4398
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8911208000000X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100027640AMedicaid
TX124606807Medicaid
NMJ8716Medicaid
TX124606806Medicaid
OK100027640AMedicaid
TXTXB106212Medicare PIN
TX124606807Medicaid