Provider Demographics
NPI:1821434432
Name:AZEVEDO, BENJAMIN M (M D, M P H)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:M
Last Name:AZEVEDO
Suffix:
Gender:M
Credentials:M D, M P H
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 122108 DEPT 2108
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2108
Mailing Address - Country:US
Mailing Address - Phone:337-494-2772
Mailing Address - Fax:337-494-2928
Practice Address - Street 1:1000 WALTERS ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4647
Practice Address - Country:US
Practice Address - Phone:337-480-8066
Practice Address - Fax:337-480-8061
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA305391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine