Basic Information
| Provider Information | |||||||||
| NPI: | 1003910720 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZWART | ||||||||
| FirstName: | BENTON | ||||||||
| MiddleName: | PHILLIPS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1716 WINDING VW | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782607219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107055030 | ||||||||
| FaxNumber: | 2107055035 | ||||||||
| Practice Location | |||||||||
| Address1: | 2833 BABCOCK, SUITE 105 | ||||||||
| Address2: | CHRISTUS SANTA ROSA HYPERBARIC AND WOUND CARE CENTER | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107055030 | ||||||||
| FaxNumber: | 2107055035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 01/12/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083A0100X | K8600 | TX | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Aerospace Medicine | 2083P0011X | K8600 | TX | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine | 2083P0500X | K8600 | TX | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine |
ID Information
| ID | Type | State | Issuer | Description | 046692205 | 05 | TX | MEDICAID |