Provider Demographics
NPI:1780656686
Name:BENAVIDES, LUIS M (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:M
Last Name:BENAVIDES
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 1:7215 MCPHERSON RD
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041
Mailing Address - Country:US
Mailing Address - Phone:956-608-4500
Mailing Address - Fax:956-608-4501
Practice Address - Street 1:7215 MCPHERSON RD
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6554
Practice Address - Country:US
Practice Address - Phone:956-724-9091
Practice Address - Fax:956-724-8213
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1378207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099236402Medicaid
TXPENDINGMedicaid
TX099236402Medicaid
TXKM61Medicare ID - Type Unspecified
TX365224ZQWQMedicare PIN