Provider Demographics
NPI:1013988708
Name:BENNETT, STEVEN WESLEY
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:WESLEY
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:STEVEN
Other - Middle Name:W
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:3300 ROYAL FERN WAY
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-1164
Mailing Address - Country:US
Mailing Address - Phone:443-447-1661
Mailing Address - Fax:410-466-2154
Practice Address - Street 1:2414 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-1722
Practice Address - Country:US
Practice Address - Phone:443-447-1661
Practice Address - Fax:410-466-2154
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01235174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD700501600Medicaid
MD367QMedicare PIN