Provider Demographics
NPI:1154303436
Name:BENITEZ, MARIE (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:BENITEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 W ESPERANZA BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-2667
Mailing Address - Country:US
Mailing Address - Phone:520-625-4401
Mailing Address - Fax:520-625-8504
Practice Address - Street 1:1260 S CAMPBELL RD
Practice Address - Street 2:
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614-0502
Practice Address - Country:US
Practice Address - Phone:520-625-3691
Practice Address - Fax:520-625-2894
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ879091Medicaid
AZ84112Medicare ID - Type Unspecified
AZ879091Medicaid