Provider Demographics
NPI:1700857786
Name:BENNETT, NORMAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:NORMAN
Middle Name:R
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 1:620 BELLE TERRE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2500
Mailing Address - Country:US
Mailing Address - Phone:631-524-5960
Mailing Address - Fax:
Practice Address - Street 1:620 BELLE TERRE RD STE 2
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2500
Practice Address - Country:US
Practice Address - Phone:631-524-5960
Practice Address - Fax:631-524-5963
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY159940207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
94D241Medicare PIN
NYA64928Medicare UPIN