Basic Information
| Provider Information | |||||||||
| NPI: | 1710903497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 416457 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022416457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443621735 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 525 CENTRAL AVE STE C | ||||||||
| Address2: | |||||||||
| City: | WESTFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735385844 | ||||||||
| FaxNumber: | 9732670181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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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 | 207RI0200X | 25MB08051400 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 25MB08051400 | 01 | NJ | STATE LICENSE | OTHER |