Provider Demographics
NPI:1871558429
Name:BENHAM, MELISA A (MD)
Entity type:Individual
Prefix:
First Name:MELISA
Middle Name:A
Last Name:BENHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 SPEIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76706-1507
Mailing Address - Country:US
Mailing Address - Phone:254-710-1010
Mailing Address - Fax:254-710-2499
Practice Address - Street 1:209 SPEIGHT AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76706-1507
Practice Address - Country:US
Practice Address - Phone:254-710-1010
Practice Address - Fax:254-710-2499
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0156207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE14881Medicare UPIN