Provider Demographics
NPI:1952409583
Name:BENAVENTE, JORGE A (OPTOMETRIST PC)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:A
Last Name:BENAVENTE
Suffix:
Gender:M
Credentials:OPTOMETRIST PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9175 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2805
Mailing Address - Country:US
Mailing Address - Phone:219-836-7800
Mailing Address - Fax:219-836-4806
Practice Address - Street 1:9175 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2805
Practice Address - Country:US
Practice Address - Phone:219-836-7800
Practice Address - Fax:219-836-4806
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-0006940152W00000X
IN18001807B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100157520AMedicaid
IN351517961OtherTAX ID
IN455560Medicare PIN