Provider Demographics
NPI:1447227806
Name:BENNETT, ROGER LEE
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:LEE
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:FROSTBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21532-2313
Mailing Address - Country:US
Mailing Address - Phone:301-689-6092
Mailing Address - Fax:
Practice Address - Street 1:83 MEADOW RD
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-2313
Practice Address - Country:US
Practice Address - Phone:301-689-6092
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman