Provider Demographics
NPI:1386978716
Name:TELEMAQUE, BENJAMIN (COTA)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:TELEMAQUE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 CLINTON AVE APT 11F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-3433
Mailing Address - Country:US
Mailing Address - Phone:718-974-9068
Mailing Address - Fax:
Practice Address - Street 1:1630 E 15TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1147
Practice Address - Country:US
Practice Address - Phone:718-787-3214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY860322424172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker