Provider Demographics
NPI:1497705958
Name:BENNETT, RICHARD HARRY (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:HARRY
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 1:90 PRESIDENTIAL PLZ
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-2240
Mailing Address - Country:US
Mailing Address - Phone:315-464-4357
Mailing Address - Fax:315-464-2030
Practice Address - Street 1:90 PRESIDENTIAL PLZ
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2240
Practice Address - Country:US
Practice Address - Phone:315-464-4357
Practice Address - Fax:315-464-2030
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY090838208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00463167Medicaid
NY00463167Medicaid
NYJ400011114Medicare PIN