Provider Demographics
NPI:1639342645
Name:SHAUGHN C BENNETT DO PA
Entity Type:Organization
Organization Name:SHAUGHN C BENNETT DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUGHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:305-926-5844
Mailing Address - Street 1:7575 SW 62ND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4955
Mailing Address - Country:US
Mailing Address - Phone:305-661-0181
Mailing Address - Fax:
Practice Address - Street 1:7575 SW 62ND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4955
Practice Address - Country:US
Practice Address - Phone:305-661-0181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1891758132OtherNPI
FL80019Medicare PIN
FLD70558Medicare UPIN