Provider Demographics
NPI:1861495236
Name:BENNETT, ANGELA M (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:M
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 1:5264 LEE RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-1232
Mailing Address - Country:US
Mailing Address - Phone:216-294-4440
Mailing Address - Fax:216-249-6032
Practice Address - Street 1:5264 LEE RD
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-1232
Practice Address - Country:US
Practice Address - Phone:216-294-4440
Practice Address - Fax:216-249-6032
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-088523207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4203042OtherMEDICARE PTAN
OH2719071Medicaid
OH4203043Medicare PIN
OH4203042OtherMEDICARE PTAN