Provider Demographics
NPI:1700879772
Name:BENITEZ, NORBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:NORBERTO
Middle Name:
Last Name:BENITEZ
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 1:309 PLANTATION CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3927
Mailing Address - Country:US
Mailing Address - Phone:904-273-1996
Mailing Address - Fax:904-280-0371
Practice Address - Street 1:274 3RD AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6727
Practice Address - Country:US
Practice Address - Phone:904-249-3373
Practice Address - Fax:904-249-3375
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2011-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44373208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069161500Medicaid
FL069161500Medicaid