Basic Information
| Provider Information | |||||||||
| NPI: | 1790050425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PLUCKNETTE | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | FOREST | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3551 ROGER BROOKE DRIVE | ||||||||
| Address2: | QUALITY SERVICES, ATTN: MCHE-ZQQ | ||||||||
| City: | JBSA - FT. SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109169817 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3551 ROGER BROOKE DRIVE | ||||||||
| Address2: | QUALITY SERVICES, ATTN: MCHE-ZQQ | ||||||||
| City: | JBSA - FT. SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109169817 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2012 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 0102203585 | VA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | 036.147240 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207XS0106X | S4546 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
No ID Information.