Provider Demographics
NPI:1962406843
Name:BENSON, ROBERT W (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:BENSON
Suffix:
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 1:180 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-2532
Mailing Address - Country:US
Mailing Address - Phone:985-370-7768
Mailing Address - Fax:
Practice Address - Street 1:180 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-2532
Practice Address - Country:US
Practice Address - Phone:985-370-7768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013754207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1175358Medicaid
LA5H235CY88Medicare PIN
LA1175358Medicaid
LA5H235Medicare PIN