Healthcare Provider Details

I. General information

NPI: 1134299308
Provider Name (Legal Business Name): JUSTIN DAVID BENNET MD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 SOQUEL DR SUITE12
SANTA CRUZ CA
95065-1716
US

IV. Provider business mailing address

1505 SOQUEL DR SUITE 12
SANTA CRUZ CA
95065-1716
US

V. Phone/Fax

Practice location:
  • Phone: 831-713-5050
  • Fax: 831-475-0101
Mailing address:
  • Phone: 831-713-5050
  • Fax: 831-475-0101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101840379
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number0101840379
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: