Provider Demographics
NPI:1962527606
Name:BASKERVILLE, BENNETT, BLOCK & LIU, A MEDICAL CORP
Entity type:Organization
Organization Name:BASKERVILLE, BENNETT, BLOCK & LIU, A MEDICAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-763-4310
Mailing Address - Street 1:4145 CLARES ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2053
Mailing Address - Country:US
Mailing Address - Phone:831-475-7442
Mailing Address - Fax:831-475-7417
Practice Address - Street 1:252 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3138
Practice Address - Country:US
Practice Address - Phone:831-475-7442
Practice Address - Fax:831-475-7417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ08030ZOtherBLUE SHIELD ID#-WV OFFICE
CAGR0099150Medicaid