Healthcare Provider Details

I. General information

NPI: 1023456290
Provider Name (Legal Business Name): ROBERT DANIEL BENNETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 N OAK ST
VALDOSTA GA
31602-2567
US

IV. Provider business mailing address

2412 N OAK ST
VALDOSTA GA
31602-2567
US

V. Phone/Fax

Practice location:
  • Phone: 229-244-1400
  • Fax: 229-244-5512
Mailing address:
  • Phone: 229-244-1400
  • Fax: 229-244-5512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number74720
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: