Provider Demographics
NPI:1538471842
Name:BENNETT, BRETT ASHLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:ASHLEY
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 1:970 LAKELAND DR
Mailing Address - Street 2:STE 61
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4634
Mailing Address - Country:US
Mailing Address - Phone:601-982-7850
Mailing Address - Fax:601-366-8507
Practice Address - Street 1:970 LAKELAND DR
Practice Address - Street 2:STE 61
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4634
Practice Address - Country:US
Practice Address - Phone:601-982-7850
Practice Address - Fax:601-366-8507
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-02
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2285207R00000X
MS22329207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS22329OtherMEDICAL LICENSE