Provider Demographics
NPI: | 1932401759 |
---|---|
Name: | BENEVENTO, JOHN DOMINICK (PT) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | JOHN |
Middle Name: | DOMINICK |
Last Name: | BENEVENTO |
Suffix: | |
Gender: | M |
Credentials: | PT |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 4800 NE 20TH TER STE 303 |
Mailing Address - Street 2: | |
Mailing Address - City: | FT LAUDERDALE |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33308-4510 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 954-771-8177 |
Mailing Address - Fax: | 945-771-3629 |
Practice Address - Street 1: | 2825 N STATE ROAD 7 STE 204 |
Practice Address - Street 2: | |
Practice Address - City: | MARGATE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33063-5737 |
Practice Address - Country: | US |
Practice Address - Phone: | 954-451-3002 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2010-11-30 |
Last Update Date: | 2020-02-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | 25858 | 172V00000X |
2251X0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No | 172V00000X | Other Service Providers | Community Health Worker |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 016620700 | Medicaid | |
FL | 016620700 | Medicaid |