Healthcare Provider Details

I. General information

NPI: 1811933005
Provider Name (Legal Business Name): BENTON NG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 5TH ST S
ST PETERSBURG FL
33701-4804
US

IV. Provider business mailing address

601 5TH ST S
ST PETERSBURG FL
33701-4804
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-3333
  • Fax: 727-767-8990
Mailing address:
  • Phone: 727-767-3333
  • Fax: 727-767-8990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number40200
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberME125328
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: