Healthcare Provider Details

I. General information

NPI: 1407874738
Provider Name (Legal Business Name): KEVIN DIBENEDETTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12525 PERKINS RD SUITE B
BATON ROUGE LA
70810-1907
US

IV. Provider business mailing address

7777 HENNESSY BLVD SUITE 1004-154
BATON ROUGE LA
70808-4300
US

V. Phone/Fax

Practice location:
  • Phone: 225-819-8857
  • Fax: 225-767-6822
Mailing address:
  • Phone: 225-214-9352
  • Fax: 225-214-9349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number017254
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: