Provider Demographics
NPI:1871803866
Name:HEWITT, BENTON E JR
Entity type:Individual
Prefix:
First Name:BENTON
Middle Name:E
Last Name:HEWITT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-3546
Mailing Address - Country:US
Mailing Address - Phone:601-924-2392
Mailing Address - Fax:
Practice Address - Street 1:230 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-4547
Practice Address - Country:US
Practice Address - Phone:662-746-3713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine