Provider Demographics
NPI:1518301399
Name:BENAVENTE, CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:BENAVENTE
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 1:2418 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2940
Mailing Address - Country:US
Mailing Address - Phone:312-666-3494
Mailing Address - Fax:
Practice Address - Street 1:2418 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2940
Practice Address - Country:US
Practice Address - Phone:949-413-0628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036141275207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036141275Medicaid
ILF400324818OtherMEDICARE PTAN
IL125064171Medicaid