Provider Demographics
NPI:1891983888
Name:BENAVIDEZ, MARISOL D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARISOL
Middle Name:D
Last Name:BENAVIDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W. 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589-2276
Mailing Address - Country:US
Mailing Address - Phone:956-787-8915
Mailing Address - Fax:956-787-2021
Practice Address - Street 1:801 W. 1ST STREET
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589
Practice Address - Country:US
Practice Address - Phone:956-787-8915
Practice Address - Fax:956-787-2021
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7855207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB142923OtherMEDICARE
TX297333101Medicaid