Provider Demographics
NPI:1225745268
Name:QUEZADA, BENITO
Entity Type:Individual
Prefix:
First Name:BENITO
Middle Name:
Last Name:QUEZADA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 INTERVALE AVE APT 5S
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-1185
Mailing Address - Country:US
Mailing Address - Phone:347-307-3189
Mailing Address - Fax:
Practice Address - Street 1:251 OLD KENT CIRCLE KISSIMMEE FL 34758
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34758
Practice Address - Country:US
Practice Address - Phone:347-748-0029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator