Provider Demographics
NPI:1821077801
Name:BENNETT, CHARLES P (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:P
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 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-929-2300
Mailing Address - Fax:
Practice Address - Street 1:430 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-8340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48798207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34823000Medicaid
WI14559OtherDEAN
WI14559OtherDEAN