Provider Demographics
NPI:1376813782
Name:BENEMED PHYSICIAN, PC
Entity Type:Organization
Organization Name:BENEMED PHYSICIAN, PC
Other - Org Name:LATINA MEDICA, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:MOI
Authorized Official - Last Name:WONG LAMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-808-8325
Mailing Address - Street 1:10119 39TH AVE
Mailing Address - Street 2:SUITE # 101
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-4806
Mailing Address - Country:US
Mailing Address - Phone:347-808-8325
Mailing Address - Fax:347-808-8326
Practice Address - Street 1:10119 39TH AVE
Practice Address - Street 2:SUITE # 101
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-4806
Practice Address - Country:US
Practice Address - Phone:347-808-8325
Practice Address - Fax:347-808-8326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258195207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY258195OtherNYS LICENSE NUMBER