Provider Demographics
NPI:1972761369
Name:BENNETT, MILES CLARK (DO)
Entity type:Individual
Prefix:DR
First Name:MILES
Middle Name:CLARK
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WINDERLEY PL
Mailing Address - Street 2:SUITE 115
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7247
Mailing Address - Country:US
Mailing Address - Phone:407-875-0555
Mailing Address - Fax:
Practice Address - Street 1:500 WINDERLEY PL
Practice Address - Street 2:SUITE 115
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7247
Practice Address - Country:US
Practice Address - Phone:407-875-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS10955207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services