Provider Demographics
NPI:1750484770
Name:BENNETT, GREGREY E (MD)
Entity Type:Individual
Prefix:
First Name:GREGREY
Middle Name:E
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:PO BOX 34960
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1960
Mailing Address - Country:US
Mailing Address - Phone:425-656-4255
Mailing Address - Fax:425-656-4003
Practice Address - Street 1:1035 116TH AVENUE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:425-688-5759
Practice Address - Fax:425-688-5101
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA27118207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8227970Medicaid
E72372Medicare UPIN
217117002Medicare ID - Type Unspecified