Basic Information
| Provider Information | |||||||||
| NPI: | 1568787836 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NORTHCUTT | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8401 DATAPOINT, SUITE 600 | ||||||||
| Address2: | P. O. BOX 29441 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782290441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106167796 | ||||||||
| FaxNumber: | 2106167799 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 W 86TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462601902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173382281 | ||||||||
| FaxNumber: | 3173386359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2010 | ||||||||
| LastUpdateDate: | 05/06/2016 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | Q7091 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.