Healthcare Provider Details

I. General information

NPI: 1114312261
Provider Name (Legal Business Name): BENYAM PETROS YOSEPH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BEN PETROS YOSEPH M.D. PH.D.

II. Dates (important events)

Enumeration Date: 04/04/2015
Last Update Date: 09/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HOME PHYSICIANS GROUP 7620 LAKE UNDERHILL RD
ORLANDO FL
32822-3282
US

IV. Provider business mailing address

1508 SOFTSHELL ST
SAINT CLOUD FL
34771-7516
US

V. Phone/Fax

Practice location:
  • Phone: 321-235-0692
  • Fax:
Mailing address:
  • Phone: 612-245-4392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number137448
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: