Provider Demographics
NPI:1679549513
Name:DEBENEDETTO, RICHARD BRUCE (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BRUCE
Last Name:DEBENEDETTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 PADRE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH PADRE ISLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78597
Mailing Address - Country:US
Mailing Address - Phone:956-761-4649
Mailing Address - Fax:866-594-1025
Practice Address - Street 1:2217 PADRE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH PADRE ISLAND
Practice Address - State:TX
Practice Address - Zip Code:78597
Practice Address - Country:US
Practice Address - Phone:956-761-4649
Practice Address - Fax:866-594-1025
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9579207PE0004X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CE910OtherBCBS
TX113326621Medicaid
TX8CE910OtherBCBSTX
TX8F23012Medicare PIN
G52899Medicare UPIN
TX113326621Medicaid