Provider Demographics
NPI:1063740744
Name:DR. JORGE A. BENAVENTE OPTOMETRIST PC
Entity type:Organization
Organization Name:DR. JORGE A. BENAVENTE OPTOMETRIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:ADAME
Authorized Official - Last Name:BENAVENTE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-836-7800
Mailing Address - Street 1:9175 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2805
Mailing Address - Country:US
Mailing Address - Phone:219-836-7800
Mailing Address - Fax:219-836-4806
Practice Address - Street 1:9175 CALUMET AVENUE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2805
Practice Address - Country:US
Practice Address - Phone:219-836-7800
Practice Address - Fax:219-836-4806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201033420AMedicaid
IN201033420AMedicaid