1710951009 NPI number — DR. LAURA A BENEDETTO D.O.

Table of content: DR. LAURA A BENEDETTO D.O. (NPI 1710951009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710951009 NPI number — DR. LAURA A BENEDETTO D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENEDETTO
Provider First Name:
LAURA
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

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:
1710951009
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
628 HEBRON AVE
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
GLASTONBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06033-5007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-657-3376
Provider Business Mailing Address Fax Number:
860-633-6040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
628 HEBRON AVE
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
GLASTONBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06033-5007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-657-3376
Provider Business Practice Location Address Fax Number:
860-633-6040
Provider Enumeration Date:
02/14/2006

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: 174400000X , with the licence number:  000275 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0492835 . This is a "CIGNA #" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 3776879 . This is a "AETNA #" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 040000275CT05 . This is a "BLUE SHIELD #" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 050275 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2V6050 . This is a "HEALTHNET #" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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