Provider Demographics
NPI:1871568899
Name:BENNETT, BERNARD LEROY (MD)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:LEROY
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 1:661 W 1ST ST STE G
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2939
Mailing Address - Country:US
Mailing Address - Phone:714-665-9890
Mailing Address - Fax:714-665-9891
Practice Address - Street 1:661 W 1ST ST STE G
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2939
Practice Address - Country:US
Practice Address - Phone:714-665-9890
Practice Address - Fax:714-665-9891
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42114207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDO0034OtherMEDICARE RAILROAD
NCDA5493OtherMEDICARE RAILROAD
NCP00651283OtherMEDICARE RAILROAD
NCP00062870OtherMEDICARE RAILROAD
NC1028POtherBLUE CROSS
NC891028PMedicaid
NC1028POtherBLUE CROSS
NCDO0034OtherMEDICARE RAILROAD
NC891028PMedicaid