Provider Demographics
NPI:1558349381
Name:SO, BENNETT TERRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:TERRENCE
Last Name:SO
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 1:8317 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4830
Mailing Address - Country:US
Mailing Address - Phone:301-776-0070
Mailing Address - Fax:301-725-7817
Practice Address - Street 1:8317 CHERRY LN
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4830
Practice Address - Country:US
Practice Address - Phone:301-776-0070
Practice Address - Fax:301-725-7817
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054488207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG90777Medicare UPIN
MD003050C00Medicare ID - Type Unspecified