Provider Demographics
NPI:1972507879
Name:DESADIER, BENNETT BENITO (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:BENITO
Last Name:DESADIER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 W 86TH ST
Mailing Address - Street 2:STE 305
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1931
Mailing Address - Country:US
Mailing Address - Phone:317-334-1692
Mailing Address - Fax:317-334-1693
Practice Address - Street 1:2020 W 86TH ST
Practice Address - Street 2:STE 305
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1931
Practice Address - Country:US
Practice Address - Phone:317-334-1692
Practice Address - Fax:317-334-1693
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN024318174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN087100Medicare ID - Type Unspecified
INB28335Medicare UPIN