Provider Demographics
NPI:1275639692
Name:BENNETT, BRIAN NATHAN (DPM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:NATHAN
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 WAINBROOK DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6289
Mailing Address - Country:US
Mailing Address - Phone:706-312-3668
Mailing Address - Fax:706-312-3670
Practice Address - Street 1:1416 WAINBROOK DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6289
Practice Address - Country:US
Practice Address - Phone:706-312-3668
Practice Address - Fax:706-312-3670
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000842213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2700070OtherUNITED HEALTHCARE
GA4292280003OtherMEDICARE PTAN
SCGPD842OtherSOUTH CAROLINA MEDICAID
GA2592457OtherAETNA HMO
GA7052274OtherBCBS OF GEORGIA
GA00812985BMedicaid
GA7104253OtherAETNA PPO
GA000812985CMedicaid
GA480032159OtherRAILROAD MEDICARE
GA480032159OtherRAILROAD MEDICARE
GAU75428Medicare UPIN
GA00812985BMedicaid