Healthcare Provider Details

I. General information

NPI: 1063740744
Provider Name (Legal Business Name): DR. JORGE A. BENAVENTE OPTOMETRIST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9175 CALUMET AVENUE
MUNSTER IN
46321-2805
US

IV. Provider business mailing address

9175 CALUMET AVE
MUNSTER IN
46321-2805
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-7800
  • Fax: 219-836-4806
Mailing address:
  • Phone: 219-836-7800
  • Fax: 219-836-4806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. JORGE ADAME BENAVENTE
Title or Position: PRESIDENT
Credential: OD
Phone: 219-836-7800