Provider Demographics
NPI:1710951009
Name:BENEDETTO, LAURA A (DO)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:A
Last Name:BENEDETTO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 HEBRON AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-5007
Mailing Address - Country:US
Mailing Address - Phone:860-657-3376
Mailing Address - Fax:860-633-6040
Practice Address - Street 1:628 HEBRON AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-5007
Practice Address - Country:US
Practice Address - Phone:860-657-3376
Practice Address - Fax:860-633-6040
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000275174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0492835OtherCIGNA #
CT3776879OtherAETNA #
CT040000275CT05OtherBLUE SHIELD #
CT050275OtherCONNECTICARE
CT2V6050OtherHEALTHNET #
CTE04337Medicare UPIN