Provider Demographics
NPI:1720562531
Name:BENAVIDEZ, ALEXANDER ISAAC (IDMT)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:ISAAC
Last Name:BENAVIDEZ
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3488 GARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-7801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 MDG
Practice Address - Street 2:UNIT 3690
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09126
Practice Address - Country:DE
Practice Address - Phone:559-359-2873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians