Provider Demographics
NPI:1477634285
Name:CAMACHO, BENITO (MD)
Entity Type:Individual
Prefix:
First Name:BENITO
Middle Name:
Last Name:CAMACHO
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 1:2214 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-3221
Mailing Address - Country:US
Mailing Address - Phone:309-680-7669
Mailing Address - Fax:309-681-8443
Practice Address - Street 1:1800 N KNOXVILLE AVE STE A
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3005
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-495-8614
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-047383207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047383Medicaid
IL1101308558 - CA4079Medicare ID - Type UnspecifiedRR
IL809870Medicare ID - Type UnspecifiedGROUP #
IL036047383Medicaid
C37677Medicare UPIN