Basic Information
| Provider Information | |||||||||
| NPI: | 1386755809 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 144333 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328144333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074229831 | ||||||||
| FaxNumber: | 8556714753 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DUNEDIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346985848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277346635 | ||||||||
| FaxNumber: | 7277346630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | MD.205664 | LA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | MD429260 | PA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 21356 | WV | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | ME154997 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 114105000 | 05 | FL | MEDICAID | 2304313 | 05 | LA | MEDICAID | 1904630 | 01 | PA | HIGHMARK | OTHER | 156840 | 01 | PA | GATEWAY | OTHER | 2698906 | 05 | OH | MEDICAID | 77644605 | 01 | AETNA PPOS | OTHER | 000000493642 | 01 | ANTHEM | OTHER | 03223248 | 05 | MS | MEDICAID | 7905789 | 01 | CIGNA | OTHER | 1393196 | 01 | AETNA HMOS | OTHER | 1017445660001 | 05 | PA | MEDICAID |