1619931417 NPI number — MR. ANTHONY LOUIS DIBENEDETTO JR. LPO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619931417 NPI number — MR. ANTHONY LOUIS DIBENEDETTO JR. LPO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIBENEDETTO
Provider First Name:
ANTHONY
Provider Middle Name:
LOUIS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
LPO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619931417
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8571 FOXWOOD COURT
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
POLAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-259-0265
Provider Business Mailing Address Fax Number:
330-259-0272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8571 FOXWOOD COURT
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
POLAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-259-0265
Provider Business Practice Location Address Fax Number:
330-259-0272
Provider Enumeration Date:
04/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 222Z00000X , with the licence number:  LPO23 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224P00000X , with the licence number: LPO23 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2347366 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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