Provider Demographics
NPI:1457320525
Name:BENNETT, WILLIAM M (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 NW 22ND AVE
Mailing Address - Street 2:SUITE 480
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-413-6555
Mailing Address - Fax:503-413-6563
Practice Address - Street 1:1040 NW 22ND AVE
Practice Address - Street 2:SUITE 480
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-413-6555
Practice Address - Fax:503-413-6563
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07668207RN0300X
WA09973207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8159055Medicaid
OR042044Medicaid
ORR00WCGSJHMedicare ID - Type Unspecified
WA8159055Medicaid