Provider Demographics
NPI:1811169683
Name:BENNIS, BROOKE E (DO)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:E
Last Name:BENNIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 BEARD RD
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-3442
Mailing Address - Country:US
Mailing Address - Phone:707-255-8825
Mailing Address - Fax:707-252-9325
Practice Address - Street 1:100 SHORELINE HIGHWAY
Practice Address - Street 2:210A
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941
Practice Address - Country:US
Practice Address - Phone:415-388-5520
Practice Address - Fax:415-388-5503
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO51271208100000X
ORDO170157208100000X
CA20A14793208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA107058Medicare PIN