Healthcare Provider Details

I. General information

NPI: 1275631640
Provider Name (Legal Business Name): BARBARA A BENTZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 13TH AVE S
FARGO ND
58103-3602
US

IV. Provider business mailing address

PO BOX 2010
FARGO ND
58122-0605
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-3620
  • Fax: 701-234-3515
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10932
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30705
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier251285800
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerMA #
# 2
Identifier379000267
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerMPIN#
# 3
Identifier061G0BE
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerIPIN#
# 4
Identifier14803
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: