Provider Demographics
NPI:1598261935
Name:BENNETT, NATASHA (DO)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6522 SOUTHERN TRACE DR
Mailing Address - Street 2:
Mailing Address - City:LEEDS
Mailing Address - State:AL
Mailing Address - Zip Code:35094-6605
Mailing Address - Country:US
Mailing Address - Phone:609-351-2093
Mailing Address - Fax:
Practice Address - Street 1:3901 BEAUBIEN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-966-0254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101026152208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics