Provider Demographics
NPI:1407878747
Name:BENNETT, PATRISE (MD)
Entity Type:Individual
Prefix:
First Name:PATRISE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5606 OLD CANTON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4217
Mailing Address - Country:US
Mailing Address - Phone:601-957-3333
Mailing Address - Fax:601-957-3334
Practice Address - Street 1:5606 OLD CANTON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-4217
Practice Address - Country:US
Practice Address - Phone:601-957-3333
Practice Address - Fax:601-957-3334
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0118967Medicaid
MS0118967Medicaid