Provider Demographics
NPI:1114990009
Name:BENNETT, GARRISON S (MD)
Entity Type:Individual
Prefix:
First Name:GARRISON
Middle Name:S
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 1:3000 WATERCOVE RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112
Mailing Address - Country:US
Mailing Address - Phone:804-744-8140
Mailing Address - Fax:804-744-7390
Practice Address - Street 1:15769 WC MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-7327
Practice Address - Country:US
Practice Address - Phone:804-419-9760
Practice Address - Fax:804-378-9140
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101102655174400000X
VA0101-102655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10002698OtherOPTIMA
VA5163353OtherUNITED HEALTHCARE
VA540883363OtherGREAT WEST
VA540883363OtherPHCS
VA540883363OtherVIRGINIA HEALTH NETWORK
VA7076211OtherAETNA
VA3071733OtherCIGNA
VA540883363OtherPREFERRED CARE
VA726824OtherSOUTHERN HEALTH
VA5163353OtherMAMSI
VA1114990009Medicaid
VA308372OtherANTHEM
VA5163353OtherMAMSI
VA3071733OtherCIGNA
VA308372OtherANTHEM
VAMC10890Medicare PIN
VA540883363OtherGREAT WEST
VA1114990009Medicaid