Provider Demographics
NPI:1851310486
Name:BENNETT, CHRISTOPHER (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
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 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:479-968-7930
Mailing Address - Fax:479-968-1673
Practice Address - Street 1:620 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2911
Practice Address - Country:US
Practice Address - Phone:479-968-7930
Practice Address - Fax:479-968-1673
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC63692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105227001Medicaid
AR50414OtherARKANSAS BCBS PROV#
AR105227001Medicaid
AR50414Medicare PIN