Provider Demographics
NPI:1053479402
Name:BENNETT, ROBERT JOSEPH JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOSEPH
Last Name:BENNETT
Suffix:JR
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 1:602 YALE PL
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4611
Mailing Address - Country:US
Mailing Address - Phone:719-275-2301
Mailing Address - Fax:719-275-7048
Practice Address - Street 1:602 YALE PL
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4611
Practice Address - Country:US
Practice Address - Phone:719-275-2301
Practice Address - Fax:719-275-7048
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01138411Medicaid
CO01138411Medicaid