Basic Information
| Provider Information | |||||||||
| NPI: | 1538471842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | ASHLEY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 970 LAKELAND DR | ||||||||
| Address2: | STE 61 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019827850 | ||||||||
| FaxNumber: | 6013668507 | ||||||||
| Practice Location | |||||||||
| Address1: | 970 LAKELAND DR | ||||||||
| Address2: | STE 61 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019827850 | ||||||||
| FaxNumber: | 6013668507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2010 | ||||||||
| LastUpdateDate: | 01/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | T-2285 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 22329 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 22329 | 01 | MS | MEDICAL LICENSE | OTHER |