Provider Demographics
NPI:1083801799
Name:LUIS BENALCAZAR, MD
Entity Type:Organization
Organization Name:LUIS BENALCAZAR, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BENALCAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-353-3628
Mailing Address - Street 1:310 MORRIS AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-3695
Mailing Address - Country:US
Mailing Address - Phone:908-353-3628
Mailing Address - Fax:908-353-3625
Practice Address - Street 1:310 MORRIS AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-3695
Practice Address - Country:US
Practice Address - Phone:908-353-3628
Practice Address - Fax:908-353-3625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07504600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0028410Medicaid
NJ075232SRAOtherCMS RENDERING NUMBER
NJ078908Medicare PIN