Basic Information
| Provider Information | |||||||||
| NPI: | 1154718849 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENEDETTO | ||||||||
| FirstName: | CONRAD | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 GARRETT RD | ||||||||
| Address2: | |||||||||
| City: | DREXEL HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190261101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106235885 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2221 GARRETT RD | ||||||||
| Address2: | |||||||||
| City: | DREXEL HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190261101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106235885 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2015 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207ND0101X | OS019881 | PA | Y | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
No ID Information.