Provider Demographics
NPI:1659355568
Name:BENNETT, DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:
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 1:215 OAK DR S
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5629
Mailing Address - Country:US
Mailing Address - Phone:979-297-6436
Mailing Address - Fax:979-297-0582
Practice Address - Street 1:215 OAK DR S
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5629
Practice Address - Country:US
Practice Address - Phone:979-297-6436
Practice Address - Fax:979-297-0582
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-05
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0811174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$OtherSOCIAL SECURITY