Provider Demographics
NPI:1457542656
Name:BENECKI, GERARD MARK (MD)
Entity type:Individual
Prefix:DR
First Name:GERARD
Middle Name:MARK
Last Name:BENECKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5040 ADDISON CIR FL 4
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3333
Mailing Address - Country:US
Mailing Address - Phone:214-983-0302
Mailing Address - Fax:214-983-0301
Practice Address - Street 1:200 KENNEDY MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4526
Practice Address - Country:US
Practice Address - Phone:207-861-7862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60866946207XX0005X, 207X00000X
TXT4497207XX0005X, 207X00000X
MEMD28345207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery