Basic Information
| Provider Information | |||||||||
| NPI: | 1710951009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENEDETTO | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 628 HEBRON AVE | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | GLASTONBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060335007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606573376 | ||||||||
| FaxNumber: | 8606336040 | ||||||||
| Practice Location | |||||||||
| Address1: | 628 HEBRON AVE | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | GLASTONBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060335007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606573376 | ||||||||
| FaxNumber: | 8606336040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 07/12/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 000275 | CT | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0492835 | 01 | CT | CIGNA # | OTHER | 3776879 | 01 | CT | AETNA # | OTHER | 040000275CT05 | 01 | CT | BLUE SHIELD # | OTHER | 050275 | 01 | CT | CONNECTICARE | OTHER | 2V6050 | 01 | CT | HEALTHNET # | OTHER |