Provider Demographics
NPI:1699768119
Name:BENNETT, JERRY D (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:D
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 1:706 LEGEND LN
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092-5421
Mailing Address - Country:US
Mailing Address - Phone:903-814-0303
Mailing Address - Fax:
Practice Address - Street 1:706 LEGEND LN
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-5421
Practice Address - Country:US
Practice Address - Phone:903-891-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9192174400000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140179633Medicaid
TX140179634Medicaid
TX85Z525OtherBCBS
TX140179634Medicaid
TXP00235520Medicare PIN
TX85Z525OtherBCBS