Healthcare Provider Details

I. General information

NPI: 1881767556
Provider Name (Legal Business Name): MICHAEL J BENTON P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E MEMORIAL RD
OKLAHOMA CITY OK
73131-1253
US

IV. Provider business mailing address

1919 E MEMORIAL RD
OKLAHOMA CITY OK
73131-1253
US

V. Phone/Fax

Practice location:
  • Phone: 405-749-7099
  • Fax: 405-216-5872
Mailing address:
  • Phone: 405-749-7099
  • Fax: 405-216-5872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1068
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: