Provider Demographics
NPI:1396081857
Name:BENNETT, SHANTE D (MD)
Entity type:Individual
Prefix:DR
First Name:SHANTE
Middle Name:D
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 1:100 NORTH ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:717-972-4379
Mailing Address - Fax:717-972-4640
Practice Address - Street 1:503 NORTH 21ST ST
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011
Practice Address - Country:US
Practice Address - Phone:717-972-4379
Practice Address - Fax:717-972-4640
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-02
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT200201208600000X
PAMD4637982085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery