MEDICARE: ORVIAL LEE BENNETT JR. PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA00212	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336223288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ORVIAL LEE BENNETT JR. PA

Provider Business Mailing Address
First Line	:	4333 N JOSEY LN STE 104
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75010-4620
Country	:	US
Telephone Number	:	972-394-4500
Fax Number	:	972-394-8180

Provider Business Practice Location Address
First Line	:	4333 N JOSEY LN STE 104
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75010-4620
Country	:	US
Telephone Number	:	972-394-4500
Fax Number	:	972-394-8180

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	03/05/2010

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