MEDICARE: JONATHAN D BENSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	01060622A	IN
2	207RG0100X	Gastroenterology Physician	44963	TN
3	208000000X	Pediatrics Physician	01060622A	IN
4	207RG0100X	Gastroenterology Physician	01060622A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4234546	OTHER	TN	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417913492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN D BENSON

Provider Business Mailing Address
First Line	:	11109 PARKVIEW PLAZA DR # 117
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11104 PARKVIEW CIRCLE DR STE 310
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1733
Country	:	US
Telephone Number	:	260-266-5230
Fax Number	:	260-266-5238

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	06/05/2023

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Directions to “ JONATHAN D BENSON ” Practice Location

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