Organization
OPHTHALMOLOGY ASSOCIATES OF BENTON, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LINDA DETHERAGE (INSURANCE & CREDENTIALING)
(501) 778-1113
Entity
Organization
Contact information
Practice address
3 MEDICAL PARK DR, SUITE 300, BENTON, AR 72015-3728
(501) 778-1113
(501) 778-5391
Mailing address
3 MEDICAL PARK DR, SUITE 300, BENTON, AR 72015-3728
(501) 778-1113
(501) 778-5391
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
C7476
AR
174400000X
Specialist
Primary
C7930
AR
174400000X
Specialist
E-2274
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
140820002
—
AR
01
—
5B790
BLUE CROSS BLUE SHIELD
AR
01
—
CI3712
RAILROAD MEDICARE
AR
Enumeration date
07/20/2005
Last updated
09/30/2013
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