Healthcare Provider Details

I. General information

NPI: 1306813894
Provider Name (Legal Business Name): COLBY MANGUN BENEVIDES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4414 LAKE BOONE TRAIL #308
RALEIGH NC
27607
US

IV. Provider business mailing address

4414 LAKE BOONE TRAIL
RALEIGH NC
27607
US

V. Phone/Fax

Practice location:
  • Phone: 919-781-7450
  • Fax: 919-781-6355
Mailing address:
  • Phone: 919-781-7450
  • Fax: 919-781-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101088
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: