Provider Demographics
NPI:1447363833
Name:BENNETT, DANIEL BRUCE (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:BRUCE
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1000 E MATTHEWS AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4307
Mailing Address - Country:US
Mailing Address - Phone:870-932-6883
Mailing Address - Fax:870-972-0719
Practice Address - Street 1:1000 E MATTHEWS AVE
Practice Address - Street 2:SUITE B
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4307
Practice Address - Country:US
Practice Address - Phone:870-932-6883
Practice Address - Fax:870-972-0719
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2282208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR138617001Medicaid
AR5L223Medicare ID - Type Unspecified
AR138617001Medicaid
ARG93327Medicare UPIN