Provider Demographics
NPI:1306945415
Name:BENAVIDES, IDALIA IVANNA (MD)
Entity type:Individual
Prefix:
First Name:IDALIA
Middle Name:IVANNA
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 TOMMINS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78214-1251
Mailing Address - Country:US
Mailing Address - Phone:210-827-1223
Mailing Address - Fax:210-921-0807
Practice Address - Street 1:161 TOMMINS AVE.
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78214
Practice Address - Country:US
Practice Address - Phone:210-924-9718
Practice Address - Fax:210-921-0807
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6286174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist