Provider Demographics
NPI:1255360525
Name:DIBENEDETTO, JEFFERY L (OD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:L
Last Name:DIBENEDETTO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2290 S RANGE AVE
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-5214
Mailing Address - Country:US
Mailing Address - Phone:225-665-2019
Mailing Address - Fax:225-665-2089
Practice Address - Street 1:2290 S RANGE AVE
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-5214
Practice Address - Country:US
Practice Address - Phone:225-665-2019
Practice Address - Fax:225-665-2089
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1321-456T152W00000X, 152WS0006X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1105350Medicaid
LA4B265Medicare PIN