Provider Demographics
NPI:1568542462
Name:BENNETT, WILLIAM RUSSELL MURRAY (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RUSSELL MURRAY
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:W R
Other - Middle Name:MURRAY
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1000 VALE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5218
Mailing Address - Country:US
Mailing Address - Phone:760-631-5000
Mailing Address - Fax:760-414-3702
Practice Address - Street 1:1000 VALE TERRACE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5218
Practice Address - Country:US
Practice Address - Phone:760-631-5000
Practice Address - Fax:760-414-3702
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC550972084A0401X, 2084P0800X, 2084P0015X, 2084P0015X
WAMD000330422084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA260038698OtherRAIL ROAD MEDICARE
WA1568542462Medicaid
WA0175022OtherL&I
3129OtherINTERNAL ID-MOTOR VEHICLE ID
WAAB03488Medicare PIN
WA260038698OtherRAIL ROAD MEDICARE
3129OtherINTERNAL ID-MOTOR VEHICLE ID