Provider Demographics
NPI:1528008125
Name:BENEDICT, MATTHEW D (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:D
Last Name:BENEDICT
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 1:1516 COTNER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3303
Mailing Address - Country:US
Mailing Address - Phone:310-445-2951
Mailing Address - Fax:310-479-1459
Practice Address - Street 1:1516 COTNER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3303
Practice Address - Country:US
Practice Address - Phone:310-445-2800
Practice Address - Fax:310-479-1459
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA891862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A891860Medicaid
CAP00408986OtherRAILROAD MEDICARE
CAI30133Medicare UPIN
CAWA89186AMedicare PIN
CAWA89186DMedicare PIN
CAWA89186CMedicare PIN
CA00A891860Medicare PIN
CA00A891862Medicare PIN
CAP00408986OtherRAILROAD MEDICARE
CAWA89186BMedicare PIN
CAAO438YMedicare PIN
CA00A891860Medicaid