Healthcare Provider Details

I. General information

NPI: 1740688530
Provider Name (Legal Business Name): BENSON O. SHITOTE N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 12/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 W RANDOL MILL RD STE 101
ARLINGTON TX
76012-4216
US

IV. Provider business mailing address

PO BOX 810196
DALLAS TX
75381-0196
US

V. Phone/Fax

Practice location:
  • Phone: 817-804-4400
  • Fax:
Mailing address:
  • Phone: 817-668-5795
  • Fax: 817-423-7389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP126400
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP126400
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: