Provider Demographics
NPI:1386614469
Name:BENNETT, CHARLES WILLIAMS (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAMS
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 1:11845 HG TRUEMAN RD
Mailing Address - Street 2:
Mailing Address - City:LUSBY
Mailing Address - State:MD
Mailing Address - Zip Code:20657-2855
Mailing Address - Country:US
Mailing Address - Phone:410-326-6344
Mailing Address - Fax:410-326-0079
Practice Address - Street 1:11845 HG TRUEMAN RD
Practice Address - Street 2:
Practice Address - City:LUSBY
Practice Address - State:MD
Practice Address - Zip Code:20657-2855
Practice Address - Country:US
Practice Address - Phone:410-326-6344
Practice Address - Fax:410-326-0079
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD25156207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKS56OtherCAREFIRST MARYLAND
0516987OtherAETNA
291571OtherMAMSI
MDT5080001OtherCAREFIRST FEDERAL PLAN
0516987OtherAETNA
D75247Medicare UPIN