Provider Demographics
NPI:1538473491
Name:BENNETT, SHELBY JAMES (MD)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:JAMES
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 1:8020 CONSTITUTION PL NE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7607
Mailing Address - Country:US
Mailing Address - Phone:505-998-3096
Mailing Address - Fax:505-998-3100
Practice Address - Street 1:8020 CONSTITUTION PL NE
Practice Address - Street 2:SUITE 202
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7607
Practice Address - Country:US
Practice Address - Phone:505-998-3096
Practice Address - Fax:505-998-3100
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2016-02262085R0204X, 2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM79288758Medicaid