Healthcare Provider Details

I. General information

NPI: 1063093425
Provider Name (Legal Business Name): JAKE BENNETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2021
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12780 RACE TRACK RD
TAMPA FL
33626-1397
US

IV. Provider business mailing address

2995 DREW ST FL 2
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 813-321-6262
  • Fax: 813-443-8150
Mailing address:
  • Phone: 727-532-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME159087
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: