Provider Demographics
NPI:1851452627
Name:BENNETT, BRENDA A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:A
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 CONVENT AVE
Mailing Address - Street 2:
Mailing Address - City:NY
Mailing Address - State:NY
Mailing Address - Zip Code:10031
Mailing Address - Country:US
Mailing Address - Phone:212-491-9890
Mailing Address - Fax:
Practice Address - Street 1:470 LENOX AVENUE
Practice Address - Street 2:SUITE #1P
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10037
Practice Address - Country:US
Practice Address - Phone:212-491-9200
Practice Address - Fax:212-690-3790
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139844207R00000X
NJ39842207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00743568Medicaid
NY0022014OtherGHI
C10061Medicare UPIN
45A101Medicare ID - Type Unspecified