Provider Demographics
NPI:1194792366
Name:DEBENEDICTIS, THOMAS HENRY (DPM)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:HENRY
Last Name:DEBENEDICTIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4808 BERGENLINE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-5172
Mailing Address - Country:US
Mailing Address - Phone:201-863-0036
Mailing Address - Fax:201-863-0727
Practice Address - Street 1:4808 BERGENLINE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-5172
Practice Address - Country:US
Practice Address - Phone:201-863-0036
Practice Address - Fax:201-863-0727
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD00155300213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3354601Medicaid
NJ4775104Medicaid
NJ1194792366OtherNPI
NJ1013076256OtherGROUP NPI
NJU18328Medicare UPIN
NJ3354601Medicaid