Provider Demographics
NPI:1831154871
Name:BENEDETTO, ANTHONY V (DO)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:V
Last Name:BENEDETTO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5605
Mailing Address - Country:US
Mailing Address - Phone:215-546-3666
Mailing Address - Fax:215-546-6060
Practice Address - Street 1:1200 LOCUST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5605
Practice Address - Country:US
Practice Address - Phone:215-546-3666
Practice Address - Fax:215-546-6060
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH59494207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD400413200Medicaid
MD400413200Medicaid
MDH766E864Medicare ID - Type Unspecified