Healthcare Provider Details

I. General information

NPI: 1609032895
Provider Name (Legal Business Name): TARA CARMEN BENTON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TARA CARMEN KUNKLER MD

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 GILLHAM RD
KANSAS CITY MO
64108-4619
US

IV. Provider business mailing address

4309 W 110TH ST
LEAWOOD KS
66211-1424
US

V. Phone/Fax

Practice location:
  • Phone: 816-234-3000
  • Fax:
Mailing address:
  • Phone: 630-212-1317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125-050752
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036122800
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number2012029906
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: