1235122896 NPI number — VICTOR BENEZRA MD

Table of content: VICTOR BENEZRA MD (NPI 1235122896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235122896 NPI number — VICTOR BENEZRA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENEZRA
Provider First Name:
VICTOR
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235122896
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
129 W HIBISCUS BLVD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32901-3006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-405-3000
Provider Business Mailing Address Fax Number:
321-722-7070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
129 W HIBISCUS BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-405-3000
Provider Business Practice Location Address Fax Number:
321-722-7070
Provider Enumeration Date:
08/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  ME89256 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VG0400X , with the licence number: ME89256 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 37523 . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 269282100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01164043 . This is a "RRMD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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