Individual
DEREK T BENNETSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
12221 MERIT DR, SUITE 1610, DALLAS, TX 75251-2202
(214) 217-1911
Mailing address
12221 MERIT DR, SUITE 1610, DALLAS, TX 75251-2202
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
M2257
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
181816301
—
TX
05
—
181816302
—
TX
05
—
181816304
—
TX
01
—
8AL417
BCBS
TX
01
—
8W0731
BCBS
TX
01
—
8W1788
BCBS
TX
05
—
90058763
—
NM
01
—
P00388057
RAILROAD
TX
Enumeration date
07/08/2006
Last updated
11/20/2008
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