Provider Demographics
NPI:1134237449
Name:BENNETT, RICARDO (DPM)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8704 ROLLING RD
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4253
Mailing Address - Country:US
Mailing Address - Phone:703-361-3132
Mailing Address - Fax:703-368-0291
Practice Address - Street 1:8704 ROLLING RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4253
Practice Address - Country:US
Practice Address - Phone:703-361-3132
Practice Address - Fax:703-368-0291
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA013001009213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
450917OtherMDIPA
450917OtherALLIANCE
71340002OtherCAREFIRST
VA258088OtherANTHEM
450917OtherUNITEDHEALTHCARE
VA53061OtherPRINCIPAL
VAFIRST HEALTHOther1077117
VA5963579OtherAETNA
VA9300325Medicaid
VA2700420OtherUNITED HEALTHCARE
VA271860OtherANTHEM
VA480023439OtherMEDICARE RR
480030235OtherMEDICARE RR
480030235OtherMEDICARE RR
VA4813150001Medicare NSC
VA258088OtherANTHEM
450917OtherMDIPA
VA480000661Medicare PIN
VA53061OtherPRINCIPAL
VA909539Medicare PIN