Provider Demographics
NPI:1558563882
Name:DEBENEDECTIS, CAROLYNN M (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYNN
Middle Name:M
Last Name:DEBENEDECTIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROLYNN
Other - Middle Name:M
Other - Last Name:CAVICCHIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD,
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-7237
Practice Address - Fax:774-441-8443
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2502022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110091971AMedicaid