Provider Demographics
NPI:1194935536
Name:BENNETT, MYLA NICOLE (MD)
Entity type:Individual
Prefix:
First Name:MYLA
Middle Name:NICOLE
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 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-962-4872
Mailing Address - Fax:765-935-8913
Practice Address - Street 1:1911 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1212
Practice Address - Country:US
Practice Address - Phone:765-962-4872
Practice Address - Fax:765-935-8913
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.097053208200000X
IN01070339A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201040990Medicaid
OH0051083Medicaid
IN000000738583OtherANTHEM
OH0051083Medicaid
IN000000738583OtherANTHEM