Individual
BENJAMIN CARL MANNIX JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1300 STATE ST, STE. 1-F, LA PORTE, IN 46350-3185
(219) 362-6297
Mailing address
1300 STATE ST, STE. 1-F, LA PORTE, IN 46350-3185
(219) 362-6297
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
01031151
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000836411
ANTHEM BCBS
IN
05
—
100335630
—
IN
01
—
151020018
MEDICARE PTAN
IN
Enumeration date
07/12/2006
Last updated
12/09/2014
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