Provider Demographics
NPI:1528088846
Name:BENNETT, NATHAN (DO)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:RATCLIFF
Mailing Address - State:AR
Mailing Address - Zip Code:72951-0130
Mailing Address - Country:US
Mailing Address - Phone:479-635-5300
Mailing Address - Fax:479-635-4700
Practice Address - Street 1:9755 W STATE HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:RATCLIFF
Practice Address - State:AR
Practice Address - Zip Code:72951-9000
Practice Address - Country:US
Practice Address - Phone:479-635-5300
Practice Address - Fax:479-635-4700
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6934207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR50443OtherAR BCBS
AR112435003Medicaid
AR112435003Medicaid
AR112435003Medicaid