Provider Demographics
NPI:1467524702
Name:BENNETT, STEPHEN J (DPM)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:J
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 1:309 E 104TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-5514
Mailing Address - Country:US
Mailing Address - Phone:212-289-3388
Mailing Address - Fax:
Practice Address - Street 1:309 E 104TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-5514
Practice Address - Country:US
Practice Address - Phone:212-289-3388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005097174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01814768Medicaid
NYPG4482Medicare PIN
NYU47719Medicare UPIN
5016590001Medicare NSC
NYP00800305Medicare PIN