Provider Demographics
NPI:1770511495
Name:BENNETT, CHRISTOPHER JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:JOSEPH
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-3750
Mailing Address - Fax:414-259-9290
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-805-3750
Practice Address - Fax:414-259-9290
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1051492085R0202X
VA01012433752085R0202X
MN532742085R0202X
IN01049476A2085R0202X
PAMD4433642085R0202X
WI714392085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03356576Medicaid
WI1770511495Medicaid
VAMC10116Medicare PIN
PA222581Medicare PIN
MN300005804Medicare PIN