Provider Demographics
NPI:1013085521
Name:BENETATOS, MICHAEL A (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:BENETATOS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 RINGWOOD AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:HASKELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07420-1451
Mailing Address - Country:US
Mailing Address - Phone:862-200-5454
Mailing Address - Fax:
Practice Address - Street 1:1069 RINGWOOD AVE STE 106
Practice Address - Street 2:
Practice Address - City:HASKELL
Practice Address - State:NJ
Practice Address - Zip Code:07420-1451
Practice Address - Country:US
Practice Address - Phone:862-200-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00509800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU31342Medicare UPIN