Provider Demographics
NPI:1508841479
Name:ANTONIO, BENJAMIN L (DO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:L
Last Name:ANTONIO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18139
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-8139
Mailing Address - Country:US
Mailing Address - Phone:919-873-9533
Mailing Address - Fax:
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4220
Practice Address - Country:US
Practice Address - Phone:984-974-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300440207LC0200X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00662391OtherRAILROAD-MEDICARE
806746OtherPARTNERS
VA10202191Medicaid
NC5901916Medicaid
7356804OtherAETNA
140P7OtherBCBS
182870OtherMEDCOST
WV3810003225Medicaid
SCQ0044GMedicaid
P00301635Medicare PIN
806746OtherPARTNERS
7356804OtherAETNA
182870OtherMEDCOST