Provider Demographics
NPI:1790753192
Name:BRENT BENNETT MD PA
Entity Type:Organization
Organization Name:BRENT BENNETT MD PA
Other - Org Name:BRENT BENNETT MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-263-7133
Mailing Address - Street 1:2300 LOHMANS SPUR
Mailing Address - Street 2:#106
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-6206
Mailing Address - Country:US
Mailing Address - Phone:512-263-7133
Mailing Address - Fax:512-263-0451
Practice Address - Street 1:2300 LOHMANS SPUR
Practice Address - Street 2:#106
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-6206
Practice Address - Country:US
Practice Address - Phone:512-263-7133
Practice Address - Fax:512-263-0451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3150207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDN3479OtherRAILROAD MEDICARE GROUP #
TX0049KZOtherBCBS OF TEXAS GROUP #
TX167436801Medicaid
TX00644WMedicare PIN