Healthcare Provider Details

I. General information

NPI: 1538145875
Provider Name (Legal Business Name): MATTHEW E BENNETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9520 W PALM LN STE 100
PHOENIX AZ
85037-4403
US

IV. Provider business mailing address

9520 W PALM LN STE 100
PHOENIX AZ
85037-4403
US

V. Phone/Fax

Practice location:
  • Phone: 623-388-3216
  • Fax: 623-388-4902
Mailing address:
  • Phone: 623-388-3216
  • Fax: 623-388-4902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29486
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: