Basic Information
| Provider Information | |||||||||
| NPI: | 1851529432 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NUNEZ | ||||||||
| FirstName: | BENJASON | ||||||||
| MiddleName: | RODRIGO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NUNEZ | ||||||||
| OtherFirstName: | JASON | ||||||||
| OtherMiddleName: | RODRIGO | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 501 N LANSDOWNE AVE | ||||||||
| Address2: | |||||||||
| City: | DREXEL HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190261114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102848100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 501 N LANSDOWNE AVE | ||||||||
| Address2: | |||||||||
| City: | DREXEL HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190261114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102848100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2009 | ||||||||
| LastUpdateDate: | 06/18/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS015682 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.