Provider Demographics
NPI:1972836104
Name:KRISTIN M BENNETT MD INC
Entity Type:Organization
Organization Name:KRISTIN M BENNETT MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-952-0483
Mailing Address - Street 1:3132 W MARCH LN
Mailing Address - Street 2:2
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2354
Mailing Address - Country:US
Mailing Address - Phone:209-952-0483
Mailing Address - Fax:209-478-5785
Practice Address - Street 1:3132 W MARCH LN
Practice Address - Street 2:2
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2354
Practice Address - Country:US
Practice Address - Phone:209-952-0483
Practice Address - Fax:209-478-5785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-04
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94636207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty