Basic Information
| Provider Information | |||||||||
| NPI: | 1417913492 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENSON | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR BLDG B | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11104 PARKVIEW CIRCLE DR STE 310 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602665230 | ||||||||
| FaxNumber: | 2602665238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 04/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01060622A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 44963 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 208000000X | 01060622A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 207RG0100X | 01060622A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 200529630 | 05 | IN | MEDICAID | 4234546 | 01 | TN | BCBS | OTHER |