Basic Information
| Provider Information | |||||||||
| NPI: | 1407063563 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DANA R BENNETT MD PC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 121 S CRESCENT DR | ||||||||
| Address2: | |||||||||
| City: | PUEBLO WEST | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810075433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195473924 | ||||||||
| FaxNumber: | 7195478368 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 S CRESCENT DR | ||||||||
| Address2: | |||||||||
| City: | PUEBLO WEST | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810075433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195473924 | ||||||||
| FaxNumber: | 7195478368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 03/07/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | PATTI | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MGR | ||||||||
| AuthorizedOfficialTelephone: | 7195473924 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 21659 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04006540 | 05 | CO | MEDICAID |