Provider Demographics
NPI:1194720912
Name:BENNETT, ROBERT TODD (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:TODD
Last Name:BENNETT
Suffix:
Gender:M
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:PO BOX 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1814 NEW HANOVER MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-5350
Practice Address - Country:US
Practice Address - Phone:910-662-8765
Practice Address - Fax:910-362-9123
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700858208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891108PMedicaid
NC1194720912Medicaid
NC2248776LMedicare PIN
NC2248776KMedicare PIN
NC2248776JMedicare PIN
NCNCL781AMedicare PIN
NC1194720912Medicaid