Healthcare Provider Details

I. General information

NPI: 1003070293
Provider Name (Legal Business Name): JAMES TOLIVER BENNETT JR. M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 SAND POINT WAY NE GENETIC MEDICINE
SEATTLE WA
98105-3901
US

IV. Provider business mailing address

4800 SAND POINT WAY NE GENETIC MEDICINE
SEATTLE WA
98105-3901
US

V. Phone/Fax

Practice location:
  • Phone: 206-987-2056
  • Fax:
Mailing address:
  • Phone: 206-987-2056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD60275601
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License NumberMD60275601
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberMD60275601
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: