Provider Demographics
NPI:1588036396
Name:BENNETT, ANDREW LEON (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:LEON
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1441 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-5420
Mailing Address - Country:US
Mailing Address - Phone:208-642-9376
Mailing Address - Fax:208-642-9598
Practice Address - Street 1:896 FORTNER ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-1787
Practice Address - Country:US
Practice Address - Phone:541-881-2828
Practice Address - Fax:541-881-2880
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00028532207Q00000X
IDM-14113207Q00000X
ORMD217581207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine