Provider Demographics
NPI:1780857417
Name:MARCO A BENITEZ MDPA
Entity Type:Organization
Organization Name:MARCO A BENITEZ MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENITEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-639-2222
Mailing Address - Street 1:511 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3127
Mailing Address - Country:US
Mailing Address - Phone:936-639-2222
Mailing Address - Fax:936-639-8810
Practice Address - Street 1:511 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3127
Practice Address - Country:US
Practice Address - Phone:936-639-2222
Practice Address - Fax:936-639-8810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL86162084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00472ZMedicare Oscar/Certification