Basic Information
| Provider Information | |||||||||
| NPI: | 1538171418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENJAMIN | ||||||||
| FirstName: | DENIS | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99371 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828854157 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828854289 | ||||||||
| FaxNumber: | 6828856111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 02/20/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | K9728 | TX | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0213X | K9728 | TX | Y | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology |
ID Information
| ID | Type | State | Issuer | Description | 7308123 | 01 | TX | AETNA PIN | OTHER | 0083EB | 01 | TX | BCBSTX GRP PIN | OTHER | 108418100 | 01 | TX | FIRSTCARE PIN | OTHER | 1750369203 | 01 | TX | GRP NPI NUMBER | OTHER | 140442847 | 05 | TX | MEDICAID | 9110676 | 01 | TX | PHCS PIN | OTHER | 105722602 | 05 | TX | MEDICAID | 85111Y | 01 | TX | BCBSTX IND PIN | OTHER | 124030 | 01 | TX | SUPERIOR PIN | OTHER | 9030385 | 01 | TX | CIGNA PIN | OTHER | 10030959 | 01 | TX | AMERIGROUP PIN | OTHER | 122646 | 01 | TX | UHC PIN | OTHER | 140442895 | 05 | TX | MEDICAID | 800011 | 01 | TX | FIRSTHEALTH PIN | OTHER | 105722601 | 05 | TX | MEDICAID |