Provider Demographics
NPI:1083698385
Name:BENNETT, MICHAEL ERNEST (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERNEST
Last Name:BENNETT
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 1:1746 COLE BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80401-3267
Mailing Address - Country:US
Mailing Address - Phone:303-914-8800
Mailing Address - Fax:
Practice Address - Street 1:938 BANNOCK ST
Practice Address - Street 2:STE. 300
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4028
Practice Address - Country:US
Practice Address - Phone:303-914-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004008062085N0700X
CO446602085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO47053739Medicaid
COC801369Medicare PIN
COC807799Medicare PIN
COC803975Medicare PIN
I34072Medicare UPIN
COC807800Medicare PIN
CO47053739Medicaid
COC809549Medicare PIN
COP00405448Medicare PIN
COC801370Medicare PIN