Provider Demographics
NPI:1851737696
Name:BENITEZ, EMMANUEL (TSSLD)
Entity Type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:
Last Name:BENITEZ
Suffix:
Gender:M
Credentials:TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:897 TIFFANY ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-4307
Mailing Address - Country:US
Mailing Address - Phone:646-842-0435
Mailing Address - Fax:
Practice Address - Street 1:897 TIFFANY ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-4307
Practice Address - Country:US
Practice Address - Phone:646-842-0435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY754352911174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist