Basic Information
| Provider Information | |||||||||
| NPI: | 1821193772 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOUNT | ||||||||
| FirstName: | BENROE | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058314761 | ||||||||
| FaxNumber: | 3058314761 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 N FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338014902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632097003 | ||||||||
| FaxNumber: | 8632843083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 02/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME123575 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.