MEDICARE: JEFFERY L. DIBENEDETTO O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1321-456T	LA
2	152WS0006X	Sports Vision Optometrist	1321-456T	LA
3	152WC0802X	Corneal and Contact Management Optometrist	1321-456T	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255360525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFERY L. DIBENEDETTO O.D.

Provider Business Mailing Address
First Line	:	2290 S RANGE AVE
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-5214
Country	:	US
Telephone Number	:	225-665-2019
Fax Number	:	225-665-2089

Provider Business Practice Location Address
First Line	:	2290 S RANGE AVE
Second Line	:
City	:	DENHAM SPRINGS
State	:	LA
Zip	:	70726-5214
Country	:	US
Telephone Number	:	225-665-2019
Fax Number	:	225-665-2089

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	01/27/2012

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