Provider Demographics
NPI:1225087539
Name:BENNETT, DAVID A (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
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:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:ELK
Mailing Address - State:WA
Mailing Address - Zip Code:99009-0129
Mailing Address - Country:US
Mailing Address - Phone:509-292-2001
Mailing Address - Fax:
Practice Address - Street 1:34705 N NEWPORT HWY
Practice Address - Street 2:
Practice Address - City:CHATTAROY
Practice Address - State:WA
Practice Address - Zip Code:99003-7711
Practice Address - Country:US
Practice Address - Phone:509-292-2001
Practice Address - Fax:509-292-9744
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000371692080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1018084Medicaid
WA1018084Medicaid