Provider Demographics
NPI:1194744854
Name:BENNETT, LOUISE B (MD)
Entity type:Individual
Prefix:
First Name:LOUISE
Middle Name:B
Last Name:BENNETT
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 1:322 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-1017
Mailing Address - Country:US
Mailing Address - Phone:585-254-6480
Mailing Address - Fax:585-254-1092
Practice Address - Street 1:322 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14608-1017
Practice Address - Country:US
Practice Address - Phone:585-254-6480
Practice Address - Fax:585-254-1092
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP010143254OtherBLUE CHOICE ROCHESTER
NY080075250OtherRAILROAD MEDICARE
NY143254Medicaid
NY100920BFOtherPREFERRED CARE
NY01258268Medicaid
NY6559OtherBLUE CROSS ROCHESTER
NY01258268Medicaid
NY6559OtherBLUE CROSS ROCHESTER
NY143254Medicaid