Provider Demographics
NPI:1205480753
Name:BENNETT, SEAN ROBERT (MD PHD)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:ROBERT
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 EDNAM DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903
Mailing Address - Country:US
Mailing Address - Phone:603-236-2258
Mailing Address - Fax:
Practice Address - Street 1:433 EDNAM DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903
Practice Address - Country:US
Practice Address - Phone:603-236-2258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240200261QR1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101242200OtherMEDICAL LICENSE