Provider Demographics
NPI:1538149125
Name:BENNETT, SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
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 1:305 MALLARD LN
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:TX
Mailing Address - Zip Code:76574-1208
Mailing Address - Country:US
Mailing Address - Phone:512-352-4777
Mailing Address - Fax:512-352-4734
Practice Address - Street 1:305 MALLARD LN
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:TX
Practice Address - Zip Code:76574-1208
Practice Address - Country:US
Practice Address - Phone:512-352-4777
Practice Address - Fax:512-352-4734
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8671207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00018120OtherRAILROAD MEDICARE
TX140069926Medicaid
TX140069930Medicaid
8J1202Medicare PIN
TX140069930Medicaid
P00018120OtherRAILROAD MEDICARE