Provider Demographics
NPI:1578563839
Name:BENNETT, JEFFREY E (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:E
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 1:4687 POUNCEY TRACT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5802
Mailing Address - Country:US
Mailing Address - Phone:804-422-5437
Mailing Address - Fax:
Practice Address - Street 1:4687 POUNCEY TRACT RD
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5802
Practice Address - Country:US
Practice Address - Phone:804-422-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102049990208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG39610Medicare UPIN