Provider Demographics
NPI:1134148042
Name:BENENSON, IGOR L (DO, MD, PHD)
Entity type:Individual
Prefix:DR
First Name:IGOR
Middle Name:L
Last Name:BENENSON
Suffix:
Gender:M
Credentials:DO, MD, PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:9892 BUSTLETON AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-2184
Mailing Address - Country:US
Mailing Address - Phone:215-969-0300
Mailing Address - Fax:215-969-4300
Practice Address - Street 1:9892 BUSTLETON AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-2184
Practice Address - Country:US
Practice Address - Phone:215-969-0300
Practice Address - Fax:215-969-4300
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2023-12-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAOS012126207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2329273000OtherINDEPENDENCE BLUE CROSS
PA200889503OtherTAX ID
PA7029541OtherAETNA
PA1009797730001Medicaid
PAI02946Medicare UPIN
PA076601SK4Medicare PIN