Provider Demographics
NPI:1194143560
Name:BENNETT, PHILLIP (IDC)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 482 BOX 2620
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96362-2699
Mailing Address - Country:US
Mailing Address - Phone:210-800-8384
Mailing Address - Fax:
Practice Address - Street 1:PSC 482 BOX 2620
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96362-2699
Practice Address - Country:US
Practice Address - Phone:210-800-8384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor