Provider Demographics
NPI:1275872145
Name:BENAVIDES, JORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:
Last Name:BENAVIDES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2970 MENDON RD
Mailing Address - Street 2:153
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-3463
Mailing Address - Country:US
Mailing Address - Phone:401-658-3566
Mailing Address - Fax:
Practice Address - Street 1:2970 MENDON RD
Practice Address - Street 2:153
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-3463
Practice Address - Country:US
Practice Address - Phone:401-658-3566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD03459208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMD03459Medicare PIN