Basic Information
| Provider Information | |||||||||
| NPI: | 1659634277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | BRENT | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 919 HIDDEN RDG | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750383813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692822713 | ||||||||
| FaxNumber: | 4692822609 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 TRINITY DR | ||||||||
| Address2: | |||||||||
| City: | HOPE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718013621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707721020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2012 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | P8116 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | E-8116 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201917001 | 05 | AR | MEDICAID | 356111001 | 05 | TX | MEDICAID | P01525303 | 01 | AR | RAILROAD MEDICARE | OTHER | P02599428 | 01 | TX | RR MCR | OTHER |