Provider Demographics
NPI:1790784155
Name:ROMANOFF, BENNETT SANFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:SANFORD
Last Name:ROMANOFF
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 1:2111 E HIGHLAND AVE STE B-240
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4741
Mailing Address - Country:US
Mailing Address - Phone:480-994-5012
Mailing Address - Fax:480-990-7364
Practice Address - Street 1:4915 E BASELINE RD STE 114
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2966
Practice Address - Country:US
Practice Address - Phone:480-830-0120
Practice Address - Fax:480-994-9479
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35037662R207W00000X
AZ62765207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0386667Medicaid
A77831Medicare UPIN
RO0453453Medicare ID - Type Unspecified