Provider Demographics
NPI:1245587161
Name:MBENZA, DIDIER (PA-C)
Entity Type:Individual
Prefix:
First Name:DIDIER
Middle Name:
Last Name:MBENZA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 N STATE ROAD 7
Mailing Address - Street 2:SUITE 211
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5600
Mailing Address - Country:US
Mailing Address - Phone:954-766-4233
Mailing Address - Fax:954-306-2056
Practice Address - Street 1:3500 N STATE ROAD 7
Practice Address - Street 2:SUITE 211
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-5600
Practice Address - Country:US
Practice Address - Phone:954-766-4233
Practice Address - Fax:954-306-2056
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106549363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9106549OtherPHYSICIAN ASSISTANT LICENSE