=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598713463
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID A BENNETT MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34705 N NEWPORT HWY
-----------------------------------------------------
City | CHATTAROY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99003-7711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-292-2001
-----------------------------------------------------
Fax | 509-292-9744
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 129
-----------------------------------------------------
City | ELK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99009-0129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-292-2001
-----------------------------------------------------
Fax | 509-292-9744
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DAVID A BENNETT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 509-292-2001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080A0000X
-----------------------------------------------------
Taxonomy Name | Pediatric Adolescent Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------