Provider Demographics
NPI:1760763114
Name:BENITEZ, ANGEL EMANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGEL
Middle Name:EMANUEL
Last Name:BENITEZ
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 1:121 FAIRWAY CT
Mailing Address - Street 2:
Mailing Address - City:BUNNELL
Mailing Address - State:FL
Mailing Address - Zip Code:32110-3411
Mailing Address - Country:US
Mailing Address - Phone:939-227-0573
Mailing Address - Fax:
Practice Address - Street 1:1425 DUNN AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1437
Practice Address - Country:US
Practice Address - Phone:386-323-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR018283208D00000X
FLACN994208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FN364AOtherCMS PTAN
PR18283OtherUPIN