Provider Demographics
NPI:1336589464
Name:BENVENUTO, ANGELO CARMELO JR (OD)
Entity Type:Individual
Prefix:DR
First Name:ANGELO
Middle Name:CARMELO
Last Name:BENVENUTO
Suffix:JR
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 1:3579 ALPINE AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-1635
Mailing Address - Country:US
Mailing Address - Phone:616-432-3591
Mailing Address - Fax:
Practice Address - Street 1:3579 ALPINE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-1635
Practice Address - Country:US
Practice Address - Phone:616-432-3591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-03
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004785152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist