Provider Demographics
NPI:1245268556
Name:BENNETT, CRAIG RANDALL (MD)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:RANDALL
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:N WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3563
Mailing Address - Country:US
Mailing Address - Phone:336-667-5039
Mailing Address - Fax:336-667-5719
Practice Address - Street 1:1914 W PARK DR
Practice Address - Street 2:
Practice Address - City:N WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3563
Practice Address - Country:US
Practice Address - Phone:336-667-5039
Practice Address - Fax:336-667-5719
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29723207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1372221NORTOtherUMWA
NC8914864Medicaid
NC203817Medicare PIN
NC8914864Medicaid