Provider Demographics
NPI:1588221253
Name:BENEVENUTO, DEBORAH (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:BENEVENUTO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8701 W WATERTOWN PLANK RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3548
Mailing Address - Country:US
Mailing Address - Phone:414-955-8998
Mailing Address - Fax:
Practice Address - Street 1:1525 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205-2591
Practice Address - Country:US
Practice Address - Phone:414-966-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74599-202084P0800X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100149489Medicaid