Provider Demographics
NPI:1295827814
Name:BENNETT, KIM D (DO)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:D
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 RURAL ACRES DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3503
Mailing Address - Country:US
Mailing Address - Phone:304-252-8551
Mailing Address - Fax:304-252-1790
Practice Address - Street 1:252 RURAL ACRES DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3503
Practice Address - Country:US
Practice Address - Phone:304-252-8551
Practice Address - Fax:304-252-1790
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1988208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3004166000Medicaid
H90133OtherHEALTH NET
2145382OtherUNITEDHEALTHCARE
321488OtherCARELINK
WV54878Medicaid
WV58941Medicaid
321488OtherCARELINK