Provider Demographics
NPI:1477505964
Name:DIBENEDETTO, ANTHONY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:THOMAS
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 1:15 ELIZABETH DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5226
Mailing Address - Country:US
Mailing Address - Phone:716-434-9141
Mailing Address - Fax:716-434-0594
Practice Address - Street 1:15 ELIZABETH DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5226
Practice Address - Country:US
Practice Address - Phone:716-434-9141
Practice Address - Fax:716-434-0594
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149223208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01081910Medicaid
NYE15527Medicare UPIN
NYBB6499Medicare ID - Type Unspecified