Provider Demographics
NPI:1629073119
Name:BENITONE, JERRY D (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:D
Last Name:BENITONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J
Other - Middle Name:D
Other - Last Name:BENITONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2144 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-4229
Mailing Address - Country:US
Mailing Address - Phone:901-274-9046
Mailing Address - Fax:901-272-7360
Practice Address - Street 1:2144 MONROE AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-4229
Practice Address - Country:US
Practice Address - Phone:901-274-9046
Practice Address - Fax:901-272-7360
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000006809174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00010364Medicaid
TN3191624Medicaid
TN3191624Medicaid
MS00010364Medicaid