Healthcare Provider Details

I. General information

NPI: 1871558429
Provider Name (Legal Business Name): MELISA A BENHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 SPEIGHT AVE
WACO TX
76706-1507
US

IV. Provider business mailing address

209 SPEIGHT AVE
WACO TX
76706-1507
US

V. Phone/Fax

Practice location:
  • Phone: 254-710-1010
  • Fax: 254-710-2499
Mailing address:
  • Phone: 254-710-1010
  • Fax: 254-710-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberH0156
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: