Healthcare Provider Details

I. General information

NPI: 1851362396
Provider Name (Legal Business Name): JEFFREY ALAN BENNETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 N WILMOT RD
TUCSON AZ
85711-2701
US

IV. Provider business mailing address

677 N WILMOT RD
TUCSON AZ
85711-2701
US

V. Phone/Fax

Practice location:
  • Phone: 520-795-2889
  • Fax: 520-795-6321
Mailing address:
  • Phone: 520-795-2889
  • Fax: 520-795-6321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number55619
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number55619
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME87320
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number53980
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: