Provider Demographics
NPI:1942438205
Name:BENNETT, ASHLEY G (MD)
Entity Type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:G
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ASHLEY
Other - Middle Name:G
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4650 W SUNSET BLVD
Mailing Address - Street 2:MS 76
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6062
Mailing Address - Country:US
Mailing Address - Phone:323-669-2113
Mailing Address - Fax:323-361-8003
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:MS 76
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-669-2113
Practice Address - Fax:323-361-8003
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27220208000000X
FLME113308208000000X
HIMD11684208000000X
CAA121634208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14KY4OtherBLUECROSS BLUE SHIELD OF FLORIDA
FL005830200Medicaid
GA003125369AMedicaid
GG720ZMedicare Oscar/Certification