Healthcare Provider Details

I. General information

NPI: 1427085075
Provider Name (Legal Business Name): KEITH G BENNETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 S MULBERRY ST
PINE BLUFF AR
71603-7030
US

IV. Provider business mailing address

PO BOX 2650
PINE BLUFF AR
71613-2650
US

V. Phone/Fax

Practice location:
  • Phone: 870-541-8747
  • Fax:
Mailing address:
  • Phone: 870-547-7211
  • Fax: 870-541-4297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC6572
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: