Provider Demographics
NPI:1871586362
Name:BENNESON, BERKLEY H (MD)
Entity type:Individual
Prefix:
First Name:BERKLEY
Middle Name:H
Last Name:BENNESON
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 1:3099 N CIVIC CENTER PLZ
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-6903
Mailing Address - Country:US
Mailing Address - Phone:480-945-3535
Mailing Address - Fax:480-994-8179
Practice Address - Street 1:3099 N CIVIC CENTER PLZ
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6903
Practice Address - Country:US
Practice Address - Phone:480-945-3535
Practice Address - Fax:480-994-8179
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9446207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ231530Medicaid
AZ231530Medicaid
C99123Medicare UPIN