Provider Demographics
NPI:1962530691
Name:BENITEZ, JOSE LUIS (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:BENITEZ
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 1:170 DRAPER AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760-3604
Mailing Address - Country:US
Mailing Address - Phone:508-695-9421
Mailing Address - Fax:508-695-1341
Practice Address - Street 1:170 DRAPER AVE
Practice Address - Street 2:
Practice Address - City:NORTH ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02760-3604
Practice Address - Country:US
Practice Address - Phone:508-695-9421
Practice Address - Fax:508-695-1341
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA241352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ46314OtherBCBS MA
MA110082636AMedicaid
MAAA153514OtherHPHC