Provider Demographics
NPI:1013076256
Name:DEBENEDICTIS & TESTA, DPM, PA
Entity Type:Organization
Organization Name:DEBENEDICTIS & TESTA, DPM, PA
Other - Org Name:DEBENEDICTIS & TESTA , DPM, PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-863-0036
Mailing Address - Street 1:4808 BERGENLINE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-5172
Mailing Address - Country:US
Mailing Address - Phone:201-863-0036
Mailing Address - Fax:201-863-0727
Practice Address - Street 1:4808 BERGENLINE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-5162
Practice Address - Country:US
Practice Address - Phone:201-863-0036
Practice Address - Fax:201-863-0727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ213ES0131X213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3354601Medicaid
NJ3354601Medicaid
NJ520246Medicare PIN