Healthcare Provider Details

I. General information

NPI: 1467458778
Provider Name (Legal Business Name): BENNETT D ORVIK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 12/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 GARTON PLZ
WESTON WV
26452-2128
US

IV. Provider business mailing address

25 GARTON PLZ
WESTON WV
26452-2128
US

V. Phone/Fax

Practice location:
  • Phone: 304-269-6620
  • Fax: 304-269-4593
Mailing address:
  • Phone: 304-269-6620
  • Fax: 304-269-4593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11386
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: