Provider Demographics
NPI:1639379126
Name:BENITO, MARYELLEN VERSOZA (DO)
Entity Type:Individual
Prefix:DR
First Name:MARYELLEN
Middle Name:VERSOZA
Last Name:BENITO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-4199
Mailing Address - Country:US
Mailing Address - Phone:646-962-9920
Mailing Address - Fax:
Practice Address - Street 1:2 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-4199
Practice Address - Country:US
Practice Address - Phone:646-962-9920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2023-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263180207Q00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program