Provider Demographics
NPI:1538189501
Name:BENNETT, ROBERT LOUIS JR (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LOUIS
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1379 E HERNDON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3309
Mailing Address - Country:US
Mailing Address - Phone:559-435-2630
Mailing Address - Fax:559-435-4319
Practice Address - Street 1:1379 E HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3309
Practice Address - Country:US
Practice Address - Phone:559-435-2630
Practice Address - Fax:559-435-4319
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46086207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF11206Medicare UPIN
CAZZZ79325ZMedicare ID - Type Unspecified