Healthcare Provider Details

I. General information

NPI: 1881857217
Provider Name (Legal Business Name): JACOB LLOYD BENFIELD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3053 W STATE ST
BRISTOL TN
37620-1720
US

IV. Provider business mailing address

3053 W STATE ST
BRISTOL TN
37620-1720
US

V. Phone/Fax

Practice location:
  • Phone: 423-301-6567
  • Fax: 423-573-9672
Mailing address:
  • Phone: 423-301-6567
  • Fax: 423-573-9672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD0000049799
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD0000049799
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: