Provider Demographics
NPI:1205932068
Name:BENEDICTO, PEDRO L (MD)
Entity type:Individual
Prefix:
First Name:PEDRO
Middle Name:L
Last Name:BENEDICTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE U # 17
Mailing Address - Street 2:URB. CASILDA
Mailing Address - City:SANTIAGO
Mailing Address - State:SANTIAGO
Mailing Address - Zip Code:00000
Mailing Address - Country:DO
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CALLE U # 17
Practice Address - Street 2:URB. CASILDA
Practice Address - City:SANTIAGO
Practice Address - State:SANTIAGO
Practice Address - Zip Code:00000
Practice Address - Country:DO
Practice Address - Phone:809-724-0874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165687174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00961968Medicaid
NY80F951Medicare ID - Type UnspecifiedNO ACTIVE
NY00961968Medicaid