Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 27OA00509800 | NJ |
NPI | 1013085521 |
---|---|
Provider Name | Dr. Michael A. Benetatos |
First Address | Haskell, NJ 07420-1451 |
Second Address | Haskell, NJ 07420-1451 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/12/2006 |
Last Update Date | 16/12/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U31342 | (02) | NJ |