Provider Demographics
NPI:1417255084
Name:MARTIN BENNETT M.D. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MARTIN BENNETT M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-784-1035
Mailing Address - Street 1:14911 MAGNOLIA BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1331
Mailing Address - Country:US
Mailing Address - Phone:818-784-1035
Mailing Address - Fax:818-784-5804
Practice Address - Street 1:14911 MAGNOLIA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1331
Practice Address - Country:US
Practice Address - Phone:818-784-1035
Practice Address - Fax:818-784-5804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA31783Medicare PIN
CAA84265Medicare UPIN