Healthcare Provider Details

I. General information

NPI: 1578609640
Provider Name (Legal Business Name): EDWARD WAYNE BENTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 E 13TH ST
MERCED CA
95340-6214
US

IV. Provider business mailing address

3568 OJAI CT
MERCED CA
95348-2220
US

V. Phone/Fax

Practice location:
  • Phone: 209-381-6800
  • Fax: 209-725-3811
Mailing address:
  • Phone: 209-723-5450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA37390
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: