Provider Demographics
NPI:1548885932
Name:DIBENEDETTO, THOMAS RAPHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RAPHAEL
Last Name:DIBENEDETTO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-4004
Mailing Address - Country:US
Mailing Address - Phone:718-280-1332
Mailing Address - Fax:
Practice Address - Street 1:2 W BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4004
Practice Address - Country:US
Practice Address - Phone:718-280-1332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist