Healthcare Provider Details

I. General information

NPI: 1720562531
Provider Name (Legal Business Name): ALEXANDER ISAAC BENAVIDEZ IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 MDG UNIT 3690
APO AE
09126
DE

IV. Provider business mailing address

3488 GARDEN AVE
FORT SAM HOUSTON TX
78234-7801
US

V. Phone/Fax

Practice location:
  • Phone: 559-359-2873
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: