Provider Demographics
NPI:1730533068
Name:FLORES, BENITO ANTONIO (OT)
Entity type:Individual
Prefix:
First Name:BENITO
Middle Name:ANTONIO
Last Name:FLORES
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:778 MORRIS PARK AVE # 38
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-3652
Mailing Address - Country:US
Mailing Address - Phone:800-678-8605
Mailing Address - Fax:
Practice Address - Street 1:778 MORRIS PARK AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-3652
Practice Address - Country:US
Practice Address - Phone:800-678-8605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-22
Last Update Date:2021-04-03
Deactivation Date:2019-07-20
Deactivation Code:
Reactivation Date:2021-04-03
Provider Licenses
StateLicense IDTaxonomies
NY011795-1225XG0600X, 225XP0019X, 225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
81-1876971OtherTIN