Healthcare Provider Details

I. General information

NPI: 1336670405
Provider Name (Legal Business Name): JULIAN R. BENAVIDEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 LAS ESTANCIAS DR SW
ALBUQUERQUE NM
87121-5504
US

IV. Provider business mailing address

3630 LAS ESTANCIAS DR SW
ALBUQUERQUE NM
87121-5504
US

V. Phone/Fax

Practice location:
  • Phone: 505-462-7777
  • Fax: 505-462-7780
Mailing address:
  • Phone: 505-462-7777
  • Fax: 505-462-7780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR.0063829
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2020-0556
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: