Provider Demographics
NPI:1871561035
Name:BENNETT, BRENT L (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2300 LOHMANS SPUR
Mailing Address - Street 2:#106
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-6206
Mailing Address - Country:US
Mailing Address - Phone:512-263-7133
Mailing Address - Fax:512-263-0451
Practice Address - Street 1:2300 LOHMANS SPUR
Practice Address - Street 2:#106
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-6206
Practice Address - Country:US
Practice Address - Phone:512-263-7133
Practice Address - Fax:512-263-0451
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG3150207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K9640OtherBCBS OF TEXAS INDIVIDUAL #
TX128045506Medicaid
TXP00123870OtherRAILROAD MEDICARE INDIVIDUAL #
TXP00123870OtherRAILROAD MEDICARE INDIVIDUAL #
TX8B8363Medicare PIN