Provider Demographics
NPI:1770703779
Name:BAJUYO, BENITO COLANCO (MD)
Entity type:Individual
Prefix:
First Name:BENITO
Middle Name:COLANCO
Last Name:BAJUYO
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 1:28 CHICK ST
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-2467
Mailing Address - Country:US
Mailing Address - Phone:618-524-2176
Mailing Address - Fax:618-524-4131
Practice Address - Street 1:1204 W 10TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2433
Practice Address - Country:US
Practice Address - Phone:618-524-3572
Practice Address - Fax:618-524-3496
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2025-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048476208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL262914OtherHEALTHLINK
IL6400025OtherBLUE CROSS ILLINOIS
IL036048476Medicaid
IL020024057OtherRAILROAD MEDICARE
IL020024057OtherRAILROAD MEDICARE
IL299000Medicare ID - Type Unspecified