Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207ND0101X | MOHS-Micrographic Surgeon | OS019881 | PA |
NPI | 1154718849 |
---|---|
Provider Name | Dr. Conrad Joseph Benedetto JR. |
First Address | Drexel Hill, PA 19026-1101 |
Second Address | Drexel Hill, PA 19026-1101 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2015 |
Last Update Date | 25/02/2021 |