Provider Demographics
NPI:1619293727
Name:BENNETT, NICHOLAS G (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:G
Last Name:BENNETT
Suffix:
Gender:M
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:P.O. BOX 173
Mailing Address - Street 2:3250 MARLETTE CIRCLE
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96156
Mailing Address - Country:US
Mailing Address - Phone:530-542-0480
Mailing Address - Fax:
Practice Address - Street 1:3250 MARLETTE CIRCLE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96156
Practice Address - Country:US
Practice Address - Phone:530-542-0480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAATE20131207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology