Provider Demographics
NPI:1538113295
Name:DIBENEDETTO, MARY C (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:DIBENEDETTO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3075 GOVERNORS PLACE BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1332
Mailing Address - Country:US
Mailing Address - Phone:937-424-8258
Mailing Address - Fax:937-424-2581
Practice Address - Street 1:3075 GOVERNORS PLACE BLVD STE 120
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45409-1332
Practice Address - Country:US
Practice Address - Phone:937-424-2580
Practice Address - Fax:937-424-3581
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA003057363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1538113295OtherNPI
GA97WCHBSMedicare ID - Type Unspecified