Provider Demographics
NPI:1578533345
Name:BENNETT, AMANDA K (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:K
Last Name:BENNETT
Suffix:
Gender:F
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:PO BOX 1680
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25707-1680
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:2585 3RD AVENUE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703
Practice Address - Country:US
Practice Address - Phone:304-781-5138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238081207Q00000X
WV21674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV00318137OtherRAILROAD MEDICARE
WV3810005272Medicaid
OH2655827Medicaid
WV2027451Medicare PIN
WV00318137OtherRAILROAD MEDICARE
WVI38144Medicare UPIN
WV3810005272Medicaid
WV2027456Medicare PIN
WVP00602981Medicare PIN