Basic Information
| Provider Information | |||||||||
| NPI: | 1609952407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTHAM | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | DAVID LEROY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22487 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457226 | ||||||||
| FaxNumber: | 9204457229 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 E SAINT JOSEPH ST | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543012241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204333630 | ||||||||
| FaxNumber: | 9204370533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0015X | 62533-20 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychosomatic Medicine | 2084P0800X | 62533-20 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0186104 | 01 | WA | L&I | OTHER | 1609952407 | 05 | WA | MEDICAID | 1609952407 | 05 | MO | MEDICAID | 276890 | 01 | INTERNAL ID-MOTOR VEHICLE ID | OTHER | 214692001 | 05 | AR | MEDICAID |