Provider Demographics
NPI:1932170461
Name:LAW, BENNIE BRET (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNIE
Middle Name:BRET
Last Name:LAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:B.
Other - Middle Name:BRET
Other - Last Name:LAW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 827
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-0827
Mailing Address - Country:US
Mailing Address - Phone:229-931-7156
Mailing Address - Fax:
Practice Address - Street 1:122 HIGHWAY 280
Practice Address - Street 2:SUITE A
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31719-8645
Practice Address - Country:US
Practice Address - Phone:229-931-7156
Practice Address - Fax:229-931-9472
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046879207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000840991BMedicaid
GA001223OtherBLUE CROSS BLUE SHEILD
GAH03945Medicare UPIN
GA08BBXMWMedicare ID - Type Unspecified