Provider Demographics
NPI:1902803190
Name:BENNOS, ERIC S (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:S
Last Name:BENNOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 270549
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75027-0549
Mailing Address - Country:US
Mailing Address - Phone:972-724-0769
Mailing Address - Fax:972-539-6485
Practice Address - Street 1:6000 BAY PARK CT
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-5576
Practice Address - Country:US
Practice Address - Phone:972-724-0769
Practice Address - Fax:972-539-6485
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG71642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122344801Medicaid
MDG7164OtherGROUP
B62610Medicare UPIN
TX122344801Medicaid