Healthcare Provider Details

I. General information

NPI: 1043895691
Provider Name (Legal Business Name): BENJAMIN MEMMOTT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 ILLINOIS AVE
FORT LEONARD WOOD MO
65473-9098
US

IV. Provider business mailing address

4234 ILLINOIS AVE
FORT LEONARD WOOD MO
65473-9098
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-0029
  • Fax:
Mailing address:
  • Phone: 573-596-0029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberT9745
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number85894
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2026033961
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number06392
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: