Provider Demographics
NPI:1336223288
Name:BENNETT, ORVIAL LEE JR (PA)
Entity Type:Individual
Prefix:
First Name:ORVIAL
Middle Name:LEE
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4333 N JOSEY LN STE 104
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4620
Mailing Address - Country:US
Mailing Address - Phone:972-394-4500
Mailing Address - Fax:972-394-8180
Practice Address - Street 1:4333 N JOSEY LN STE 104
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4620
Practice Address - Country:US
Practice Address - Phone:972-394-4500
Practice Address - Fax:972-394-8180
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00212363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184447404Medicaid
TX184447402Medicaid
TX184447403Medicaid
TX8L18978Medicare PIN
TX8L18980Medicare PIN
TX184447402Medicaid
TX8L18979Medicare PIN