=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952355471
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUES BENUN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2006
-----------------------------------------------------
Last Update Date | 08/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11714 WILSON PARKE AVE STE 150
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78726-4061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-346-6611
-----------------------------------------------------
Fax | 512-406-6267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6210 E HWY 290
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78723-1142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-483-9596
-----------------------------------------------------
Fax | 512-406-6216
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 09645
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080P0006X
-----------------------------------------------------
Taxonomy Name | Developmental - Behavioral Pediatrics Physician
-----------------------------------------------------
License Number | R0192
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | R0192
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------