Healthcare Provider Details

I. General information

NPI: 1053397703
Provider Name (Legal Business Name): HERNAN G. BENAVIDES O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 07/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 E BROAD ST
EUFAULA AL
36027-2024
US

IV. Provider business mailing address

PO BOX 635
EUFAULA AL
36072-0635
US

V. Phone/Fax

Practice location:
  • Phone: 334-687-2545
  • Fax: 334-687-6491
Mailing address:
  • Phone: 334-687-2545
  • Fax: 334-687-6491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS-387-TA-013
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: