Provider Demographics
NPI:1104309533
Name:BENAVIDEZ, MARIE ANTOINETTE (CCP, LP)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ANTOINETTE
Last Name:BENAVIDEZ
Suffix:
Gender:F
Credentials:CCP, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 KINGBIRD CT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-4463
Mailing Address - Country:US
Mailing Address - Phone:210-712-3710
Mailing Address - Fax:
Practice Address - Street 1:3463 MAGIC DR STE T21
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3621
Practice Address - Country:US
Practice Address - Phone:212-210-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXFPF02000054242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist