Provider Demographics
NPI:1669505335
Name:BENOWICZ, ROBERT EMERY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EMERY
Last Name:BENOWICZ
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 1:17230 LAKE HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-6514
Mailing Address - Country:US
Mailing Address - Phone:503-319-3044
Mailing Address - Fax:
Practice Address - Street 1:408 W CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-5120
Practice Address - Country:US
Practice Address - Phone:503-319-3044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0600003375208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTRES000Medicare UPIN