Provider Demographics
NPI:1134299308
Name:BENNET, JUSTIN DAVID (MD PHD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DAVID
Last Name:BENNET
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 SOQUEL DR
Mailing Address - Street 2:SUITE 12
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1716
Mailing Address - Country:US
Mailing Address - Phone:831-713-5050
Mailing Address - Fax:831-475-0101
Practice Address - Street 1:1505 SOQUEL DR
Practice Address - Street 2:SUITE12
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1716
Practice Address - Country:US
Practice Address - Phone:831-713-5050
Practice Address - Fax:831-475-0101
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101840379207RG0100X, 207RI0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005847958Medicaid
006468G00Medicare ID - Type Unspecified
G00454Medicare UPIN
721300Medicare ID - Type UnspecifiedGROUP #