Provider Demographics
NPI:1073549895
Name:BENNIE, ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:
Last Name:BENNIE
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 1:4149 SUN 'N LAKE BLVD.
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872
Mailing Address - Country:US
Mailing Address - Phone:863-314-0165
Mailing Address - Fax:863-385-2582
Practice Address - Street 1:4200 SUN N LAKE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-1986
Practice Address - Country:US
Practice Address - Phone:863-402-3447
Practice Address - Fax:863-402-3448
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME985782085R0204X
FLME 985782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY769T51OtherNY MEDICARE
NY026660346OtherNY MEDICAID