Individual
MR. ROOSEVELT BENNETT JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
AA-C
Contact information
Practice address
807 CHILDRENS WAY, NEMOURS CHILDRENS SPECIALTY CARE, JACKSONVILLE, JACKSONVILLE, FL 32207-8426
(904) 697-3600
(904) 697-3927
Mailing address
PO BOX 191, PROVIDER ENROLLMENT DEPARTMENT, ROCKLAND, DE 19732-0191
(904) 697-4201
(302) 651-4945
Taxonomy
Speciality
Code
Description
License number
State
367H00000X
Anesthesiologist Assistant
Primary
AA100
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004228800
—
FL
Enumeration date
10/23/2011
Last updated
01/09/2017
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