Basic Information
| Provider Information | |||||||||
| NPI: | 1861728297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENVENISTE | ||||||||
| FirstName: | MARCELO | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4439 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137922991 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1515 HOLCOMBE BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770304000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137926161 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2009 | ||||||||
| LastUpdateDate: | 01/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 42646 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | P4930 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 207943601 | 05 | TX | MEDICAID | 8W0999 | 01 | TX | BCBS | OTHER | P00803068 | 01 | TX | RR MEDICARE | OTHER | 207943602 | 01 | TX | MEDICAID CSHCN | OTHER |