Provider Demographics
NPI:1992096572
Name:GERVACIO, BENCLEMENT (MD)
Entity type:Individual
Prefix:DR
First Name:BENCLEMENT
Middle Name:
Last Name:GERVACIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:BENCLEMENT
Other - Middle Name:
Other - Last Name:NADADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2339 27TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3109
Mailing Address - Country:US
Mailing Address - Phone:718-879-1600
Mailing Address - Fax:
Practice Address - Street 1:3722 82ND ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7040
Practice Address - Country:US
Practice Address - Phone:718-932-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-29
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276622207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY276622OtherMEDICAL LICENSE