Provider Demographics
NPI:1477507911
Name:RAINE-BENNETT, TINA RENEE (MD)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:RENEE
Last Name:RAINE-BENNETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:RENEE
Other - Last Name:RAINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:DOR - KPNC
Mailing Address - Street 2:2101 WEBSTER 20TH FLOOR
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3011
Mailing Address - Country:US
Mailing Address - Phone:510-627-2740
Mailing Address - Fax:510-627-2520
Practice Address - Street 1:280 W MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5642
Practice Address - Country:US
Practice Address - Phone:510-752-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84337207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G843370Medicaid
CA00G843370Medicare ID - Type Unspecified
CA00G843370Medicaid