Healthcare Provider Details

I. General information

NPI: 1609952407
Provider Name (Legal Business Name): WAYNE DAVID LEROY BENTHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 TALMAGE CIR STE 216
VADNAIS HEIGHTS MN
55110-7100
US

IV. Provider business mailing address

3640 TALMAGE CIR STE 216
VADNAIS HEIGHTS MN
55110-7100
US

V. Phone/Fax

Practice location:
  • Phone: 952-431-5330
  • Fax: 952-431-5334
Mailing address:
  • Phone: 952-431-5330
  • Fax: 951-431-5334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number62533-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number62533-20
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number68407
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: