Provider Demographics
NPI:1699834796
Name:BENNETT, RICHARD LEROY JR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEROY
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 1:1510 NORTH 28TH STREET
Mailing Address - Street 2:SUITE 207
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223
Mailing Address - Country:US
Mailing Address - Phone:804-649-0044
Mailing Address - Fax:804-649-0758
Practice Address - Street 1:1510 NORTH 28TH STREET
Practice Address - Street 2:SUITE 207
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223
Practice Address - Country:US
Practice Address - Phone:804-649-0044
Practice Address - Fax:804-649-0758
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233413208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6737188Medicaid
H80222Medicare UPIN