Provider Demographics
NPI:1942252770
Name:BENECK, NEIL (MD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:
Last Name:BENECK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 WAVERLEY OAKS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-8448
Mailing Address - Country:US
Mailing Address - Phone:781-891-3706
Mailing Address - Fax:781-891-3564
Practice Address - Street 1:465 WAVERLEY OAKS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-8438
Practice Address - Country:US
Practice Address - Phone:781-643-7700
Practice Address - Fax:781-891-3564
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA46230208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110002671AMedicaid
MAJ0257401Medicare PIN
MA110002671AMedicaid