Provider Demographics
NPI:1063491199
Name:BENNETT, CYNTHIA ELAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:ELAINE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 N NEVADA AVE
Mailing Address - Street 2:STE 5020
Mailing Address - City:COLORADO SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6868
Mailing Address - Country:US
Mailing Address - Phone:719-776-5960
Mailing Address - Fax:719-776-5045
Practice Address - Street 1:2222 N NEVADA AVE
Practice Address - Street 2:STE 5020
Practice Address - City:COLORADO SPGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6868
Practice Address - Country:US
Practice Address - Phone:719-776-5960
Practice Address - Fax:719-776-5045
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41710225400000X
WAMD00048553204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80031064Medicaid
WA5160BEOtherBLUE SHIELD VM
WA8493199Medicaid
WA8493199Medicaid
COH23849Medicare UPIN
COCO301120Medicare PIN
COC500328Medicare PIN