1083069264 NPI number — JEAN MARIE-REMONIDA BENNETT MD

Table of content: JEAN MARIE-REMONIDA BENNETT MD (NPI 1083069264)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083069264 NPI number — JEAN MARIE-REMONIDA BENNETT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT
Provider First Name:
JEAN
Provider Middle Name:
MARIE-REMONIDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083069264
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60TH MEDICAL GROUP
Provider Second Line Business Mailing Address:
101 BODIN CIRCLE, BUILDING 777
Provider Business Mailing Address City Name:
TRAVIS AIR FORCE BASE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94535-1801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-423-5323
Provider Business Mailing Address Fax Number:
707-423-7446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60TH MEDICAL GROUP
Provider Second Line Business Practice Location Address:
101 BODIN CIRCLE, BUILDING 777
Provider Business Practice Location Address City Name:
TRAVIS AIR FORCE BASE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94535-1801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-423-5323
Provider Business Practice Location Address Fax Number:
707-423-7446
Provider Enumeration Date:
04/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  0101268030 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com