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General NPI Number Information
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NPI Number | 1568787836
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Entity Type | Individual
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Provider Name | BENJAMIN GORDON NORTHCUTT M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/30/2010
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Last Update Date | 05/06/2016
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Provider Practice Location Address
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Address Line | 2001 W 86TH ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46260-1902
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Country | US
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Telephone | 317-338-2281
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Fax | 317-338-6359
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Provider Business Mailing Address
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Address Line | 8401 DATAPOINT, SUITE 600 P. O. BOX 29441
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City | SAN ANTONIO
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State | TX
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Zip | 78229-0441
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Country | US
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Telephone | 210-616-7796
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Fax | 210-616-7799
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | Q7091
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License Number State | TX
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