Healthcare Provider Details

I. General information

NPI: 1891766580
Provider Name (Legal Business Name): THOMAS BB BENTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5612 NW 43RD ST
GAINESVILLE FL
32653-3332
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 352-376-4542
  • Fax: 352-376-4959
Mailing address:
  • Phone: 352-376-4542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME53353
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: