Provider Demographics
NPI:1942468426
Name:EDWARDS-BENNETT, SOPHIA MAE (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:MAE
Last Name:EDWARDS-BENNETT
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:1970 GOLF ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-6908
Practice Address - Country:US
Practice Address - Phone:941-957-1000
Practice Address - Fax:941-951-2117
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD344832085R0001X
SCTL344832085R0001X
NY24405-12085R0203X
FLME1080662085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4952170OtherCIGNA
SC692677OtherWELLCARE
SC80023852OtherSELECT HEALTH
SC9322600OtherAETNA
SCP01070951OtherRAILROAD MEDICARE
SC344835Medicaid
NC5921093Medicaid
SCAA86875714Medicare PIN