Provider Demographics
NPI:1487616272
Name:BENNETT, MARTY NEAL (MD)
Entity type:Individual
Prefix:
First Name:MARTY
Middle Name:NEAL
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 1:16479 DALLAS PKWY STE 320
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-6709
Mailing Address - Country:US
Mailing Address - Phone:469-484-4260
Mailing Address - Fax:469-484-4265
Practice Address - Street 1:16479 DALLAS PKWY STE 320
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-6709
Practice Address - Country:US
Practice Address - Phone:469-484-4260
Practice Address - Fax:469-484-4265
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL00292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151750001Medicaid
TX8127B7Medicare ID - Type Unspecified
TX151750001Medicaid