Provider Demographics
NPI:1902473754
Name:BENACCI, JOHN BENJAMIN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BENJAMIN
Last Name:BENACCI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:BENJAMIN
Other - Last Name:BENACCI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:701 W 5TH ST STE 1229
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-4206
Mailing Address - Country:US
Mailing Address - Phone:432-703-5238
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 37
Practice Address - Street 2:
Practice Address - City:LOCKNEY
Practice Address - State:TX
Practice Address - Zip Code:79241-0037
Practice Address - Country:US
Practice Address - Phone:806-652-3373
Practice Address - Fax:806-652-2172
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXU5928207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program