Provider Demographics
NPI:1831185644
Name:BENITEZ-BRAUER, MARIA CORAZON VILLAREAL (MD)
Entity type:Individual
Prefix:
First Name:MARIA CORAZON
Middle Name:VILLAREAL
Last Name:BENITEZ-BRAUER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 E MAIN ST STE 4
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2602
Mailing Address - Country:US
Mailing Address - Phone:615-822-8388
Mailing Address - Fax:615-822-8336
Practice Address - Street 1:625 E MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2602
Practice Address - Country:US
Practice Address - Phone:615-822-8388
Practice Address - Fax:615-822-8336
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31145208000000X
TNMD31145208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
G22820Medicare UPIN
TN3496772Medicare ID - Type Unspecified