Healthcare Provider Details

I. General information

NPI: 1033386222
Provider Name (Legal Business Name): MICHAEL A BENETATOS OD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 10/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1069 RINGWOOD AVE
HASKELL NJ
07420-1408
US

IV. Provider business mailing address

1069 RINGWOOD AVE
HASKELL NJ
07420-1408
US

V. Phone/Fax

Practice location:
  • Phone: 862-200-5454
  • Fax: 862-200-5453
Mailing address:
  • Phone: 862-200-5454
  • Fax: 862-200-5453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00509800
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier132242
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerMEDICARE PTAN
# 2
Identifier7757204
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: DR. MICHAEL BENETATOS
Title or Position: OPERATING MANAGER
Credential: O.D.
Phone: 862-200-5454