Provider Demographics
NPI:1578092193
Name:BENNETT, BROCK TANNER (MD)
Entity type:Individual
Prefix:DR
First Name:BROCK
Middle Name:TANNER
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 1:520 MEDICAL CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4316
Mailing Address - Country:US
Mailing Address - Phone:541-930-8907
Mailing Address - Fax:541-245-4820
Practice Address - Street 1:520 MEDICAL CENTER DR STE 300
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4316
Practice Address - Country:US
Practice Address - Phone:541-930-8907
Practice Address - Fax:541-245-4820
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD2187202086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208600000XAllopathic & Osteopathic PhysiciansSurgery