Provider Demographics
NPI:1659373330
Name:BENNETT, CHARLES NELSON (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:NELSON
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 1:301 S PALM AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-4143
Mailing Address - Country:US
Mailing Address - Phone:386-328-7493
Mailing Address - Fax:386-328-4137
Practice Address - Street 1:301 S PALM AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-4143
Practice Address - Country:US
Practice Address - Phone:386-328-7493
Practice Address - Fax:386-328-4137
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL035737207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7522348OtherAETNA
FL042618100Medicaid
FL042618100Medicaid
FLD63480Medicare UPIN