MEDICARE: SUZANNE DIBENEDETTO LDO

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	156FX1800X	Optician	3875	NJ

General Provider Information

NPI Number	:	1780375717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE DIBENEDETTO LDO

Provider Business Mailing Address
First Line	:	6801 BLACK HORSE PIKE
Second Line	:
City	:	EGG HARBOR TOWNSHIP
State	:	NJ
Zip	:	08234-4115
Country	:	US
Telephone Number	:	609-415-6350
Fax Number	:	609-484-8702

Provider Business Practice Location Address
First Line	:	6801 BLACK HORSE PIKE
Second Line	:
City	:	EGG HARBOR TOWNSHIP
State	:	NJ
Zip	:	08234-4115
Country	:	US
Telephone Number	:	609-415-6350
Fax Number	:	609-484-8702

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

Provider Enumeration Date	:	05/19/2023
Last Update Date	:	05/19/2023

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