Provider Demographics
NPI:1750666095
Name:JOSE B. BENIGNO MEDICAL CLINIC, P.A.
Entity Type:Organization
Organization Name:JOSE B. BENIGNO MEDICAL CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:BATO
Authorized Official - Last Name:BENIGNO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:432-367-4817
Mailing Address - Street 1:115 W 42ND ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79764-4001
Mailing Address - Country:US
Mailing Address - Phone:432-367-4817
Mailing Address - Fax:432-367-4813
Practice Address - Street 1:115 W 42ND ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79764-4001
Practice Address - Country:US
Practice Address - Phone:432-367-4817
Practice Address - Fax:432-367-4813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171721701Medicaid
TX171721701Medicaid
TX00210WMedicare PIN