Healthcare Provider Details

I. General information

NPI: 1659373330
Provider Name (Legal Business Name): CHARLES NELSON BENNETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S PALM AVE
PALATKA FL
32177-4143
US

IV. Provider business mailing address

301 S PALM AVE
PALATKA FL
32177-4143
US

V. Phone/Fax

Practice location:
  • Phone: 386-328-7493
  • Fax: 386-328-4137
Mailing address:
  • Phone: 386-328-7493
  • Fax: 386-328-4137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number035737
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: