Healthcare Provider Details

I. General information

NPI: 1811342355
Provider Name (Legal Business Name): OLIVIA ZOFIA BENTKOWSKI GINNARD DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OLIVIA ZOFIA BENTKOWSKI DO

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6621 FANNIN ST
HOUSTON TX
77030-2358
US

IV. Provider business mailing address

6621 FANNIN ST
HOUSTON TX
77030-2399
US

V. Phone/Fax

Practice location:
  • Phone: 832-822-3780
  • Fax:
Mailing address:
  • Phone: 832-822-3780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10056543
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: