Healthcare Provider Details

I. General information

NPI: 1255329173
Provider Name (Legal Business Name): DEBORAH RAYE BENNETT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30880 BECK RD
NOVI MI
48377
US

IV. Provider business mailing address

3116 N STOCKTON HILL RD
KINGMAN AZ
86401-4183
US

V. Phone/Fax

Practice location:
  • Phone: 248-926-0009
  • Fax: 248-926-8972
Mailing address:
  • Phone: 928-681-8742
  • Fax: 928-681-8743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4710
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101009622
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: