Provider Demographics
NPI:1548509532
Name:GEORGE, BENJAMIN (PA)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:
Last Name:GEORGE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3033
Mailing Address - Country:US
Mailing Address - Phone:817-336-8855
Mailing Address - Fax:817-336-4228
Practice Address - Street 1:1000 COLLEGE AVENUE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-336-8855
Practice Address - Fax:817-336-4228
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0234207RA0201X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology