Provider Demographics
NPI:1639127095
Name:BENNETT, CHARLES JOSEPH JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOSEPH
Last Name:BENNETT
Suffix:JR
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 1:2020 SE 17TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-4118
Mailing Address - Country:US
Mailing Address - Phone:352-861-0440
Mailing Address - Fax:352-414-4229
Practice Address - Street 1:522 N LECANTO HWY
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-8547
Practice Address - Country:US
Practice Address - Phone:352-527-0106
Practice Address - Fax:352-527-0585
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME588882085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375141400Medicaid
FLE23487Medicare UPIN
18675ZMedicare ID - Type Unspecified