Provider Demographics
NPI:1619931417
Name:DIBENEDETTO, ANTHONY LOUIS JR (LPO)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:LOUIS
Last Name:DIBENEDETTO
Suffix:JR
Gender:M
Credentials:LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8571 FOXWOOD COURT
Mailing Address - Street 2:SUITE C
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514
Mailing Address - Country:US
Mailing Address - Phone:330-259-0265
Mailing Address - Fax:330-259-0272
Practice Address - Street 1:8571 FOXWOOD COURT
Practice Address - Street 2:SUITE C
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514
Practice Address - Country:US
Practice Address - Phone:330-259-0265
Practice Address - Fax:330-259-0272
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPO23222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2347366Medicaid
OH2347366Medicaid