Provider Demographics
NPI:1184900177
Name:BENNETT, ROOSEVELT JR (AA-C)
Entity type:Individual
Prefix:MR
First Name:ROOSEVELT
Middle Name:
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:AA-C
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Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:904-697-4201
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:NEMOURS CHILDRENS SPECIALTY CARE, JACKSONVILLE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-697-3600
Practice Address - Fax:904-697-3927
Is Sole Proprietor?:No
Enumeration Date:2011-10-23
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLAA100367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004228800Medicaid