Healthcare Provider Details

I. General information

NPI: 1386614469
Provider Name (Legal Business Name): CHARLES WILLIAMS BENNETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11845 HG TRUEMAN RD
LUSBY MD
20657-2855
US

IV. Provider business mailing address

11845 HG TRUEMAN RD
LUSBY MD
20657-2855
US

V. Phone/Fax

Practice location:
  • Phone: 410-326-6344
  • Fax: 410-326-0079
Mailing address:
  • Phone: 410-326-6344
  • Fax: 410-326-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD25156
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: