Provider Demographics
NPI:1033386222
Name:MICHAEL A BENETATOS OD LLC
Entity Type:Organization
Organization Name:MICHAEL A BENETATOS OD LLC
Other - Org Name:HASKELL EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATING MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BENETATOS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:862-200-5454
Mailing Address - Street 1:1069 RINGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HASKELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07420-1408
Mailing Address - Country:US
Mailing Address - Phone:862-200-5454
Mailing Address - Fax:862-200-5453
Practice Address - Street 1:1069 RINGWOOD AVE
Practice Address - Street 2:
Practice Address - City:HASKELL
Practice Address - State:NJ
Practice Address - Zip Code:07420-1408
Practice Address - Country:US
Practice Address - Phone:862-200-5454
Practice Address - Fax:862-200-5453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00509800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ132242OtherMEDICARE PTAN
NJ7757204Medicaid
NYU31342Medicare UPIN