Provider Demographics
NPI:1962404996
Name:TIMMONS, BENSON ELLISON LANE IV (MD)
Entity type:Individual
Prefix:DR
First Name:BENSON
Middle Name:ELLISON LANE
Last Name:TIMMONS
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 X RAY DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7488
Mailing Address - Country:US
Mailing Address - Phone:704-671-1094
Mailing Address - Fax:704-671-1095
Practice Address - Street 1:649 N NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7424
Practice Address - Country:US
Practice Address - Phone:704-866-4005
Practice Address - Fax:704-866-0450
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39341208200000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
8354XOtherBCBS
2165882FOtherMEDICARE
NC898354XMedicaid
2165882GOtherMEDICARE
F08809Medicare UPIN
2165882DMedicare PIN