MEDICARE: ROGER LAFE BENJAMIN OD

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	152W00000X	Optometrist	3759T	TX

General Provider Information

NPI Number	:	1437143708
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER LAFE BENJAMIN OD

Provider Business Mailing Address
First Line	:	400 NORTHPORT DR
Second Line	:
City	:	CABOT
State	:	AR
Zip	:	72023-6022
Country	:	US
Telephone Number	:	501-605-8038
Fax Number	:

Provider Business Practice Location Address
First Line	:	314 MDOS/SGOAE
Second Line	:	1090 ARNOLD DRIVE
City	:	LITTLE ROCK AFB
State	:	AR
Zip	:	72099-0001
Country	:	US
Telephone Number	:	501-987-8072
Fax Number	:

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

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	07/08/2007

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