Provider Demographics
NPI:1437484268
Name:MICHAEL A BENAVIDES DO PA
Entity Type:Organization
Organization Name:MICHAEL A BENAVIDES DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, OWNER,PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENAVIDES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-682-5757
Mailing Address - Street 1:PO BOX 570543
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75357-0543
Mailing Address - Country:US
Mailing Address - Phone:972-682-5757
Mailing Address - Fax:972-682-6611
Practice Address - Street 1:1350 N BUCKNER BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-3558
Practice Address - Country:US
Practice Address - Phone:972-682-5757
Practice Address - Fax:972-682-6611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-13
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6044207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3475816-02Medicaid
TX3475816-01Medicaid
TX404389Medicare PIN