Provider Demographics
NPI:1417479742
Name:BENEVIDES DE MESQUITA NETO, JOSE WILSON (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE WILSON
Middle Name:
Last Name:BENEVIDES DE MESQUITA NETO
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 1:5102 BUCKINGHAM
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-2610
Mailing Address - Country:US
Mailing Address - Phone:313-329-8899
Mailing Address - Fax:
Practice Address - Street 1:3990 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2018
Practice Address - Country:US
Practice Address - Phone:313-745-4195
Practice Address - Fax:313-993-8669
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301113123390200000X
AL45215208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program