Provider Demographics
NPI:1407906654
Name:BENNETT, WILLIAM A (DPM)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:A
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 1:2085 INLAND DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1203
Mailing Address - Country:US
Mailing Address - Phone:541-756-3332
Mailing Address - Fax:541-756-2370
Practice Address - Street 1:2085 INLAND DR
Practice Address - Street 2:SUITE B
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-1203
Practice Address - Country:US
Practice Address - Phone:541-756-3332
Practice Address - Fax:541-756-2370
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP000000561213E00000X
ORDP00270213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U60303Medicare UPIN