Provider Demographics
NPI:1437195005
Name:BENITEZ COLON, CARLOS R
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:R
Last Name:BENITEZ COLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB HACIENDA REAL
Mailing Address - Street 2:443 REINA DE LAS FLORES
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987
Mailing Address - Country:US
Mailing Address - Phone:787-250-0084
Mailing Address - Fax:787-772-7731
Practice Address - Street 1:LAS AMERICAS PROFESIONAL CENTER
Practice Address - Street 2:DOMENECH 400 SUITE 607
Practice Address - City:HATO REY
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-250-0084
Practice Address - Fax:787-772-7731
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11575207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0084463Medicare ID - Type Unspecified
PRG40953Medicare UPIN