Provider Demographics
NPI:1164606448
Name:BENJO, ALEXANDRE MIGUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDRE
Middle Name:MIGUEL
Last Name:BENJO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3709 N CAMPBELL AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-1563
Mailing Address - Country:US
Mailing Address - Phone:520-320-3918
Mailing Address - Fax:
Practice Address - Street 1:1714 W ANKLAM RD
Practice Address - Street 2:SUITE #104
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2689
Practice Address - Country:US
Practice Address - Phone:520-838-3540
Practice Address - Fax:520-325-3526
Is Sole Proprietor?:No
Enumeration Date:2007-12-22
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS23004207RC0000X
LAMD206266207RI0011X
AZ505941207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08985016Medicaid
LA2334018Medicaid
LA2334018Medicaid