Provider Demographics
NPI:1922068600
Name:BENNETT, WILLIAM IRA (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:IRA
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:21 LEXINGTON AVE
Mailing Address - Street 2:2
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2608
Mailing Address - Country:US
Mailing Address - Phone:617-666-7707
Mailing Address - Fax:617-628-1617
Practice Address - Street 1:49 HANCOCK ST
Practice Address - Street 2:204
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3188
Practice Address - Country:US
Practice Address - Phone:617-576-6199
Practice Address - Fax:617-628-1617
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2011-07-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA738762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3124151Medicaid
F80777Medicare UPIN
J14565Medicare ID - Type Unspecified