Healthcare Provider Details

I. General information

NPI: 1891873469
Provider Name (Legal Business Name): LISA D. BENTON MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 WATER CREST LN
COLUMBUS OH
43209-3337
US

IV. Provider business mailing address

2055 WATER CREST LN
COLUMBUS OH
43209-3337
US

V. Phone/Fax

Practice location:
  • Phone: 415-746-0627
  • Fax: 614-255-0763
Mailing address:
  • Phone: 415-746-0627
  • Fax: 614-255-0763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number35.092443
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG028077
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: