Basic Information
| Provider Information | |||||||||
| NPI: | 1245349620 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 110429 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800420429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034937300 | ||||||||
| FaxNumber: | 3034937202 | ||||||||
| Practice Location | |||||||||
| Address1: | 12700 E 19TH AVE | ||||||||
| Address2: | PO BOX B182 | ||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800452560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037246450 | ||||||||
| FaxNumber: | 3037244329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 02/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 33654 | CO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 01336544 | 05 | CO | MEDICAID |