Provider Demographics
NPI:1477535565
Name:BENTLEY, VINCENT CARL (MD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:CARL
Last Name:BENTLEY
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 1:300 EAST HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905
Mailing Address - Country:US
Mailing Address - Phone:706-787-9355
Mailing Address - Fax:706-787-7201
Practice Address - Street 1:300 EAST HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:706-787-9355
Practice Address - Fax:706-787-7201
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033798207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAVAD000Medicare UPIN