Provider Demographics
NPI:1336115864
Name:BENITEZ, MARISENDA (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARISENDA
Middle Name:
Last Name:BENITEZ
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 WASHINGTON ST
Mailing Address - Street 2:SUITE 505
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-3505
Mailing Address - Country:US
Mailing Address - Phone:847-336-9930
Mailing Address - Fax:847-336-9937
Practice Address - Street 1:2504 WASHINGTON ST
Practice Address - Street 2:SUITE 505
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-3505
Practice Address - Country:US
Practice Address - Phone:847-336-9930
Practice Address - Fax:847-336-9937
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL316-002339213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6318020001OtherDME
IL016005165Medicaid
IL0001623503OtherBLUE CROSS
IL5410292OtherCIGNA
ILPTAN# POO414506OtherRAILROAD GROUP CG8029
IL016005165Medicaid
IL1208030001Medicare NSC
IL5410292OtherCIGNA
ILK40969Medicare PIN