Provider Demographics
NPI:1679644397
Name:DIBENEDETTO, MICHAEL RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:DIBENEDETTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:30544 HIGHWAY 200
Mailing Address - Street 2:STE 102
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-5005
Mailing Address - Country:US
Mailing Address - Phone:208-265-9817
Mailing Address - Fax:208-265-4533
Practice Address - Street 1:30544 HIGHWAY 200
Practice Address - Street 2:STE 102
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-5005
Practice Address - Country:US
Practice Address - Phone:208-265-9817
Practice Address - Fax:208-265-4533
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM8578207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID77010OtherBLUE CROSS
ID806452000Medicaid
IDP00042698OtherPALMETTOGBA RAILROAD MEDI
ID000010140056OtherREGENCE
F77409Medicare UPIN
ID5302280001Medicare NSC
ID11066821Medicare PIN