Healthcare Provider Details

I. General information

NPI: 1003020074
Provider Name (Legal Business Name): GARY BENNETT M.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E CHAPMAN AVE
ORANGE CA
92869
US

IV. Provider business mailing address

1913 E 17TH ST STE 118
SANTA ANA CA
92705-8627
US

V. Phone/Fax

Practice location:
  • Phone: 714-633-0011
  • Fax:
Mailing address:
  • Phone: 714-547-3346
  • Fax: 714-547-3252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG40059
License Number StateCA

VIII. Authorized Official

Name: DIANA COFFMAN
Title or Position: BILLER
Credential:
Phone: 714-547-3346