Provider Demographics
NPI:1629166137
Name:BENNETT, RODERICK NEAL (MD)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:NEAL
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 1:303 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2709
Mailing Address - Country:US
Mailing Address - Phone:386-254-4000
Mailing Address - Fax:
Practice Address - Street 1:303 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-254-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200060207P00000X
FLME98577207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17217OtherBCBS
LA1063878Medicaid
FLP00438668OtherRR MEDICARE
FL278376200Medicaid
LAI48457Medicare UPIN
LA1063878Medicaid
AE485YMedicare PIN
FLP00438668OtherRR MEDICARE
LA4K021Medicare PIN
FL17217OtherBCBS