Healthcare Provider Details

I. General information

NPI: 1760416648
Provider Name (Legal Business Name): RICHARD GARY BENNETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 20TH ST SUITE 570
SANTA MONICA CA
90404-2050
US

IV. Provider business mailing address

1301 20TH ST SUITE 570
SANTA MONICA CA
90404-2050
US

V. Phone/Fax

Practice location:
  • Phone: 310-315-0171
  • Fax: 310-828-6647
Mailing address:
  • Phone: 310-315-0171
  • Fax: 310-828-6647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG50297
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: