Provider Demographics
NPI:1255329173
Name:BENNETT, DEBORAH RAYE (DO)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:RAYE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3116 N STOCKTON HILL RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4183
Mailing Address - Country:US
Mailing Address - Phone:928-681-8742
Mailing Address - Fax:928-681-8743
Practice Address - Street 1:30880 BECK RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377
Practice Address - Country:US
Practice Address - Phone:248-926-0009
Practice Address - Fax:248-926-8972
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4710207Q00000X
MI5101009622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4103599Medicaid
OM82910Medicare ID - Type Unspecified
MI4103599Medicaid