Provider Demographics
NPI:1134186513
Name:WILLARD, BENNETT L (DO)
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:L
Last Name:WILLARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 GLENWOOD HILLS PKWY SE STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2091
Mailing Address - Country:US
Mailing Address - Phone:616-940-2662
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:2060 E PARIS AVE SE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6113
Practice Address - Country:US
Practice Address - Phone:616-285-1377
Practice Address - Fax:616-285-1154
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008161207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI555410027OtherBCBSM
MI4610008-11Medicaid
MI4535360-11Medicaid
MI4609992-11Medicaid
MI5212687-11Medicaid
MI4610008-11Medicaid
MI4535360-11Medicaid