Provider Demographics
NPI:1316340821
Name:ORDONEZ, BENITO JR
Entity type:Individual
Prefix:MR
First Name:BENITO
Middle Name:
Last Name:ORDONEZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5966 N MANTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5553
Mailing Address - Country:US
Mailing Address - Phone:177-382-2708
Mailing Address - Fax:188-831-6099
Practice Address - Street 1:5966 N MANTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5553
Practice Address - Country:US
Practice Address - Phone:177-382-2708
Practice Address - Fax:188-831-6099
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILO63506080017172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver