Provider Demographics
NPI:1982119939
Name:BENITEZ, ELDIS
Entity Type:Individual
Prefix:MR
First Name:ELDIS
Middle Name:
Last Name:BENITEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 W 23RD ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-1921
Mailing Address - Country:US
Mailing Address - Phone:786-915-2606
Mailing Address - Fax:
Practice Address - Street 1:1400 NE 125TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-6034
Practice Address - Country:US
Practice Address - Phone:305-915-8900
Practice Address - Fax:866-599-2563
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCCM101522-A171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty