Provider Demographics
NPI:1023312246
Name:ROBERTA K BENNETT MD
Entity type:Organization
Organization Name:ROBERTA K BENNETT MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-442-3520
Mailing Address - Street 1:160 BENMONT AVE STE 20
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-1842
Mailing Address - Country:US
Mailing Address - Phone:802-442-3570
Mailing Address - Fax:802-447-3392
Practice Address - Street 1:160 BENMONT AVE STE 20
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-1842
Practice Address - Country:US
Practice Address - Phone:802-442-3570
Practice Address - Fax:802-447-3392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00074242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0005143Medicaid
VT0005143Medicaid