Provider Demographics
NPI:1760478887
Name:BENAVIDES, ANGELA (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BENAVIDES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 MIDTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1271
Mailing Address - Country:US
Mailing Address - Phone:815-220-2693
Mailing Address - Fax:
Practice Address - Street 1:1400 MIDTOWN RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1269
Practice Address - Country:US
Practice Address - Phone:815-220-2693
Practice Address - Fax:815-220-2640
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360742772084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036074277Medicaid
ILC48731Medicare UPIN