Healthcare Provider Details

I. General information

NPI: 1477535565
Provider Name (Legal Business Name): VINCENT CARL BENTLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 EAST HOSPITAL ROAD
FORT GORDON GA
30905
US

IV. Provider business mailing address

300 EAST HOSPITAL ROAD
FORT GORDON GA
30905
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-9355
  • Fax: 706-787-7201
Mailing address:
  • Phone: 706-787-9355
  • Fax: 706-787-7201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number033798
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: