Provider Demographics
NPI:1861666018
Name:CLINICA MEDICA DE DALLAS, P.A.
Entity Type:Organization
Organization Name:CLINICA MEDICA DE DALLAS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENIGNO
Authorized Official - Middle Name:
Authorized Official - Last Name:BUENTIPO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:214-823-5590
Mailing Address - Street 1:4811A COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75226-1034
Mailing Address - Country:US
Mailing Address - Phone:214-823-5590
Mailing Address - Fax:214-823-6638
Practice Address - Street 1:4811A COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75226-1034
Practice Address - Country:US
Practice Address - Phone:214-823-5590
Practice Address - Fax:214-823-6638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00496UMedicare PIN