Provider Demographics
NPI:1063493922
Name:BENNETT, JENNIFER L (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:509 S ARMENIA AVE STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3395
Practice Address - Country:US
Practice Address - Phone:813-974-2201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69510207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272137600Medicaid
FL46820OtherBLUE CROSS BLUE SHIELD
FLP00174993OtherRAILROAD MEDICARE
FL262931OtherAVMED
FL892750853OtherCLINICIAN PROVIDER ID
FLN166134OtherWELLCARE PROVIDER NUMBER
FL46820OtherBCBS OF FLORIDA