Healthcare Provider Details

I. General information

NPI: 1962497305
Provider Name (Legal Business Name): BENNY POTHEN PHILLIPS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 22ND ST SUITE 100
LUBBOCK TX
79410-1301
US

IV. Provider business mailing address

3621 22ND ST SUITE 100
LUBBOCK TX
79410-1301
US

V. Phone/Fax

Practice location:
  • Phone: 806-796-1317
  • Fax: 806-796-0426
Mailing address:
  • Phone: 806-796-1317
  • Fax: 806-796-0426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberF2851
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: