Provider Demographics
NPI:1548233562
Name:BENNETT, TODD C (DO)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:C
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 74
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-8481
Mailing Address - Fax:269-341-7781
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:BOX 74
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-8481
Practice Address - Fax:269-341-7781
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017091208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICA2184OtherRAILROAD MEDICARE
MI4930034Medicaid
MI4930034Medicaid
MII46609Medicare UPIN