Provider Demographics
NPI:1730185802
Name:CLOSE, BENJAMIN B (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:B
Last Name:CLOSE
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 1:201 PECAN PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3361
Mailing Address - Country:US
Mailing Address - Phone:318-445-6221
Mailing Address - Fax:318-445-5399
Practice Address - Street 1:201 PECAN PARK AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3361
Practice Address - Country:US
Practice Address - Phone:318-445-6221
Practice Address - Fax:318-445-5399
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019414174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1951650Medicaid
LA1951650Medicaid
LA5R079 GRP ID# 5B265Medicare ID - Type Unspecified