Provider Demographics
NPI:1427051911
Name:BENNETT, THOMAS OMAR (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:OMAR
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 1:8679 CONNECTICUT ST
Mailing Address - Street 2:STE A
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6383
Mailing Address - Country:US
Mailing Address - Phone:219-769-9022
Mailing Address - Fax:219-769-1918
Practice Address - Street 1:8679 CONNECTICUT ST
Practice Address - Street 2:STE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6383
Practice Address - Country:US
Practice Address - Phone:219-769-9022
Practice Address - Fax:219-769-1918
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030607A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100167860Medicaid
INC25222Medicare UPIN
IN100167860Medicaid