Provider Demographics
NPI:1598746604
Name:BENEDETTI, GARY E (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:E
Last Name:BENEDETTI
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 1:112 EAST FIFTH AVE
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-2710
Mailing Address - Country:US
Mailing Address - Phone:715-623-2331
Mailing Address - Fax:907-745-2600
Practice Address - Street 1:112 EAST FIFTH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2710
Practice Address - Country:US
Practice Address - Phone:715-623-2331
Practice Address - Fax:907-745-2600
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI61642-20207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400122143Medicare PIN
AKH65271Medicare UPIN
AKMD7891Medicaid
AKK160646Medicare PIN