Provider Demographics
NPI:1235174319
Name:BENIN, YURY (PT)
Entity Type:Individual
Prefix:
First Name:YURY
Middle Name:
Last Name:BENIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 AVENUE P
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1507
Mailing Address - Country:US
Mailing Address - Phone:718-338-1616
Mailing Address - Fax:718-338-1898
Practice Address - Street 1:2116 AVENUE P
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1507
Practice Address - Country:US
Practice Address - Phone:718-338-1616
Practice Address - Fax:718-338-1898
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010179174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02144383Medicaid
NYQ66321Medicare ID - Type Unspecified
NY02144383Medicaid