Provider Demographics
NPI:1003020074
Name:GARY BENNETT M.D. INC
Entity Type:Organization
Organization Name:GARY BENNETT M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-547-3346
Mailing Address - Street 1:1913 E 17TH ST STE 118
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-8627
Mailing Address - Country:US
Mailing Address - Phone:714-547-3346
Mailing Address - Fax:714-547-3252
Practice Address - Street 1:2601 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869
Practice Address - Country:US
Practice Address - Phone:714-633-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40059207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48067Medicare UPIN
CAG40059AMedicare ID - Type Unspecified