=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649834508
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN OZBUN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2019
-----------------------------------------------------
Last Update Date | 09/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 47 S FOURTH ST
-----------------------------------------------------
City | ROLLING FORK
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39159-5146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-873-5205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1346 MARATHON PT
-----------------------------------------------------
City | GLEN ALLAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38744-9666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-822-9676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 30545
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------