MEDICARE: DEREK T BENNETSEN DO

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	207P00000X	Emergency Medicine Physician	M2257	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8AL417	OTHER	TX	BCBS
2	P00388057	OTHER	TX	RAILROAD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	8W1788	OTHER	TX	BCBS
8	8W0731	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1720011232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK T BENNETSEN DO

Provider Business Mailing Address
First Line	:	12221 MERIT DR
Second Line	:	SUITE 1610
City	:	DALLAS
State	:	TX
Zip	:	75251-2202
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12221 MERIT DR
Second Line	:	SUITE 1610
City	:	DALLAS
State	:	TX
Zip	:	75251-2202
Country	:	US
Telephone Number	:	214-217-1911
Fax Number	:

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

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	11/20/2008

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Directions to “ DEREK T BENNETSEN DO” Practice Location

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