Provider Demographics
NPI:1770640294
Name:D A BENEDETTO MD PA
Entity Type:Organization
Organization Name:D A BENEDETTO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOMINICK
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENEDETTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-436-1150
Mailing Address - Street 1:124 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002
Mailing Address - Country:US
Mailing Address - Phone:201-436-1150
Mailing Address - Fax:201-436-0161
Practice Address - Street 1:124 AVENUE B
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002
Practice Address - Country:US
Practice Address - Phone:201-436-1150
Practice Address - Fax:201-436-0161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA3211800207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0538890001Medicare NSC
NJ617844Medicare ID - Type Unspecified