Provider Demographics
NPI:1215189378
Name:BENNETT, MATTHEW A (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:M
Other - Middle Name:
Other - Last Name:A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:624 RIVER RD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-6563
Mailing Address - Country:US
Mailing Address - Phone:716-332-2300
Mailing Address - Fax:716-332-2280
Practice Address - Street 1:624 RIVER RD
Practice Address - Street 2:SUITE#1
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-6563
Practice Address - Country:US
Practice Address - Phone:716-332-2300
Practice Address - Fax:716-332-2280
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250570207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY250570OtherLICENSE