Basic Information
| Provider Information | |||||||||
| NPI: | 1942438205 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | G | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4650 W SUNSET BLVD | ||||||||
| Address2: | MS 76 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236692113 | ||||||||
| FaxNumber: | 3233618003 | ||||||||
| Practice Location | |||||||||
| Address1: | 4650 W SUNSET BLVD | ||||||||
| Address2: | MS 76 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236692113 | ||||||||
| FaxNumber: | 3233618003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 03/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 27220 | OK | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | ME113308 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD11684 | HI | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | A121634 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 14KY4 | 01 | FL | BLUECROSS BLUE SHIELD OF FLORIDA | OTHER | 005830200 | 05 | FL | MEDICAID | 003125369A | 05 | GA | MEDICAID |