Provider Demographics
NPI:1609985613
Name:BENNETT, BRADLEY HOLMES (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:HOLMES
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4701 RANDOLPH RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-2257
Mailing Address - Country:US
Mailing Address - Phone:301-681-6437
Mailing Address - Fax:301-681-0975
Practice Address - Street 1:4701 RANDOLPH RD
Practice Address - Street 2:SUITE 203
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-2257
Practice Address - Country:US
Practice Address - Phone:301-681-6437
Practice Address - Fax:301-681-0975
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0026752208C00000X
DCMD11630208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCM11630OtherLICENSE
MDD0026752OtherLICENSE