Healthcare Provider Details

I. General information

NPI: 1952864274
Provider Name (Legal Business Name): ABRAHAM BENAVIDES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 LAKEVIEW AVE
PUEBLO CO
81004-3597
US

IV. Provider business mailing address

902 LAKEVIEW AVE
PUEBLO CO
81004-3597
US

V. Phone/Fax

Practice location:
  • Phone: 719-557-5872
  • Fax: 719-557-4780
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTL.0007818
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTL.0007818
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: