Provider Demographics
NPI:1225007818
Name:BENNETT, BRUCE WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:WAYNE
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE
Mailing Address - Street 2:STE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3331
Mailing Address - Country:US
Mailing Address - Phone:918-307-5525
Mailing Address - Fax:918-307-5526
Practice Address - Street 1:10507 E 91ST ST STE 510
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5462
Practice Address - Country:US
Practice Address - Phone:918-307-5525
Practice Address - Fax:918-307-5526
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15660207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100107490AMedicaid