Provider Demographics
NPI:1891766077
Name:BENNETT, BRIAN CHARLES (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHARLES
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 1:3821 ED DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-8038
Mailing Address - Country:US
Mailing Address - Phone:919-851-5482
Mailing Address - Fax:919-859-1729
Practice Address - Street 1:3821 ED DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-8038
Practice Address - Country:US
Practice Address - Phone:919-851-5482
Practice Address - Fax:919-859-1729
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500827208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89133GFMedicaid
NC14792OtherBLUECROSSBLUESHIELD
NC14792OtherBLUECROSSBLUESHIELD
2211183AMedicare ID - Type Unspecified