Provider Demographics
NPI:1629030945
Name:PEREZ-BENAVIDES, FORTUNATO (MD)
Entity Type:Individual
Prefix:
First Name:FORTUNATO
Middle Name:
Last Name:PEREZ-BENAVIDES
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 1:306 VICKSBURG AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3105
Mailing Address - Country:US
Mailing Address - Phone:806-797-6053
Mailing Address - Fax:
Practice Address - Street 1:602 INDIANA AVE
Practice Address - Street 2:NICU, UNIVERSITY MEDICAL CENTER
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-3364
Practice Address - Country:US
Practice Address - Phone:806-775-8808
Practice Address - Fax:806-775-9181
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH87942080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141691903Medicaid
TX141691903Medicaid