Provider Demographics
NPI:1457419616
Name:TANO, BENOIT D (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:BENOIT
Middle Name:D
Last Name:TANO
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 HEBRON AVE
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2421
Mailing Address - Country:US
Mailing Address - Phone:860-659-8904
Mailing Address - Fax:
Practice Address - Street 1:622 HEBRON AVE
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2421
Practice Address - Country:US
Practice Address - Phone:860-659-8904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPT11501207RA0201X
TXM4963207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
M4963OtherTEXAS MEDICAL LICENSE