Provider Demographics
NPI:1770518441
Name:BENNETT, BRUCE KEVIN (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:KEVIN
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 1:716 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-1645
Mailing Address - Country:US
Mailing Address - Phone:973-777-1444
Mailing Address - Fax:973-777-4488
Practice Address - Street 1:220 HAMBURG TPKE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2110
Practice Address - Country:US
Practice Address - Phone:973-790-8090
Practice Address - Fax:973-790-3198
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06066100207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1790731271OtherGROUP NPI
NJ39114OtherUNIVERSITY HEALTH PLANS
NJ6233007Medicaid
NJ39114OtherUNIVERSITY HEALTH PLANS
NJ1790731271OtherGROUP NPI