Provider Demographics
NPI:1053397703
Name:BENAVIDES, HERNAN G (OD)
Entity type:Individual
Prefix:DR
First Name:HERNAN
Middle Name:G
Last Name:BENAVIDES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:EUFAULA
Mailing Address - State:AL
Mailing Address - Zip Code:36072-0635
Mailing Address - Country:US
Mailing Address - Phone:334-687-2545
Mailing Address - Fax:334-687-6491
Practice Address - Street 1:138 E BROAD ST
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:AL
Practice Address - Zip Code:36027-2024
Practice Address - Country:US
Practice Address - Phone:334-687-2545
Practice Address - Fax:334-687-6491
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-387-TA-013152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000267495AMedicaid
AL59471OtherTRICARE
AL51059471OtherBCBS
AL000059471Medicaid
180006842Medicare PIN
0161840001Medicare NSC
000059471Medicare PIN
AL000059471Medicaid