Provider Demographics
NPI:1114925443
Name:CHAVEZ, BENNIE
Entity Type:Individual
Prefix:
First Name:BENNIE
Middle Name:
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BEN
Other - Middle Name:
Other - Last Name:CHAVEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3113 ROSS ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79103-2700
Mailing Address - Country:US
Mailing Address - Phone:806-374-7341
Mailing Address - Fax:805-322-0533
Practice Address - Street 1:3113 ROSS ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79103-2700
Practice Address - Country:US
Practice Address - Phone:806-374-7341
Practice Address - Fax:806-322-0533
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF01241OtherUPIN
TXP00060898OtherRAILROAD MEDICARE
TX8B2862OtherMEDICARE ID/UNSPECIFIED
TX8B2862OtherMEDICARE ID/UNSPECIFIED
TX8B2862OtherMEDICARE ID/UNSPECIFIED