Provider Demographics
NPI:1407063563
Name:DANA R BENNETT MD PC
Entity Type:Organization
Organization Name:DANA R BENNETT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:F
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-547-3924
Mailing Address - Street 1:121 S CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-5433
Mailing Address - Country:US
Mailing Address - Phone:719-547-3924
Mailing Address - Fax:719-547-8368
Practice Address - Street 1:121 S CRESCENT DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-5433
Practice Address - Country:US
Practice Address - Phone:719-547-3924
Practice Address - Fax:719-547-8368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21659207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04006540Medicaid
CO04006540Medicaid
CE4708Medicare ID - Type UnspecifiedGROUP
D23971Medicare UPIN
CO01216597Medicare ID - Type UnspecifiedINDIVIDUAL