Basic Information
| Provider Information | |||||||||
| NPI: | 1154303436 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENITEZ | ||||||||
| FirstName: | MARIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 81 W ESPERANZA BLVD | ||||||||
| Address2: | STE 201 | ||||||||
| City: | GREEN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856142667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206254401 | ||||||||
| FaxNumber: | 5206258504 | ||||||||
| Practice Location | |||||||||
| Address1: | 1260 S CAMPBELL RD | ||||||||
| Address2: | |||||||||
| City: | GREEN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856140502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206253691 | ||||||||
| FaxNumber: | 5206252894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 01/17/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 30014 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 879091 | 05 | AZ | MEDICAID |