Provider Demographics
NPI:1538173398
Name:BENTON, LOUIS W (MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:W
Last Name:BENTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5640
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:421 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7236
Practice Address - Country:US
Practice Address - Phone:601-268-5640
Practice Address - Fax:601-261-3507
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13508207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1559327OtherAMERICAN ADMIN GROUP
MS00120425Medicaid
LA1419923Medicaid
160043453OtherRAILROAD MEDICARE
G91666Medicare UPIN
MS160000409Medicare PIN