MEDICARE: DR. LISA D. BENTON MD, MPH

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	2083P0901X	Public Health & General Preventive Medicine Physician	35.092443	OH
2	208600000X	Surgery Physician	G028077	CA

General Provider Information

NPI Number	:	1891873469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA D. BENTON MD, MPH

Provider Business Mailing Address
First Line	:	2055 WATER CREST LN
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43209-3337
Country	:	US
Telephone Number	:	415-746-0627
Fax Number	:	614-255-0763

Provider Business Practice Location Address
First Line	:	2055 WATER CREST LN
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43209-3337
Country	:	US
Telephone Number	:	415-746-0627
Fax Number	:	614-255-0763

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	04/18/2013

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