Provider Demographics
NPI:1013022979
Name:BENITEZ, MARCO A (MD)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:A
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 1:3006 S 1ST ST STE B
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-7112
Mailing Address - Country:US
Mailing Address - Phone:936-639-2222
Mailing Address - Fax:936-639-8810
Practice Address - Street 1:3006 S 1ST ST STE B
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-7112
Practice Address - Country:US
Practice Address - Phone:936-639-2222
Practice Address - Fax:936-639-8810
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1455262084N0400X
TXL86162084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177021601Medicaid
H39510Medicare UPIN
TX177021601Medicaid