Provider Demographics
NPI:1407874738
Name:DIBENEDETTO, KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:DIBENEDETTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:SUITE 1004-154
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-214-9352
Mailing Address - Fax:225-214-9349
Practice Address - Street 1:12525 PERKINS RD
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1907
Practice Address - Country:US
Practice Address - Phone:225-819-8857
Practice Address - Fax:225-767-6822
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1336408Medicaid
LA930113224OtherRRM
LA5L287C822Medicare PIN
LA5L287DU45Medicare PIN
LA5L287CN33Medicare PIN
LA1336408Medicaid
LA5L287DE56Medicare PIN