MEDICARE: DR. FREDERICK S BENNETT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0801X	Orthopaedic Trauma Physician	G64646	CA
2	207X00000X	Orthopaedic Surgery Physician	G64646	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	00G646460	OTHER	CA	CIGNA DME
3	G64646	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1205879830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FREDERICK S BENNETT M.D.

Provider Business Mailing Address
First Line	:	1405 MONTGOMERY DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-4557
Country	:	US
Telephone Number	:	707-546-1922
Fax Number	:	707-546-1897

Provider Business Practice Location Address
First Line	:	1162 MONTGOMERY DR STE 3
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-4802
Country	:	US
Telephone Number	:	707-890-4250
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	07/14/2023

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Directions to “ DR. FREDERICK S BENNETT M.D.” Practice Location

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