Provider Demographics
NPI:1427085075
Name:BENNETT, KEITH G (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:G
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:PO BOX 2650
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-2650
Mailing Address - Country:US
Mailing Address - Phone:870-547-7211
Mailing Address - Fax:870-541-4297
Practice Address - Street 1:4310 S MULBERRY ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7030
Practice Address - Country:US
Practice Address - Phone:870-541-8747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6572207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR115670001Medicaid
ARE02947Medicare UPIN
AR52890Medicare PIN