Provider Demographics
NPI:1114191871
Name:BENNETT- GITTENS, RAQUEL LISA (MD)
Entity type:Individual
Prefix:DR
First Name:RAQUEL
Middle Name:LISA
Last Name:BENNETT- GITTENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 MANCHESTER EXPY STE 2001A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6802
Mailing Address - Country:US
Mailing Address - Phone:706-320-3126
Mailing Address - Fax:706-320-3054
Practice Address - Street 1:610 19TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1528
Practice Address - Country:US
Practice Address - Phone:706-322-7884
Practice Address - Fax:706-660-2118
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA70713207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I061193OtherMEDICARE PTAN
GA003140208BMedicaid