Provider Demographics
NPI:1033189717
Name:BENNETT, JOHN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:281 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-3126
Practice Address - Country:US
Practice Address - Phone:828-245-6400
Practice Address - Fax:828-245-3838
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32922207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC080115284OtherMEDICARE RR
NC2150033EOtherMEDICARE PIN
SCP01445426OtherRAILROAD MEDICARE
SC44365OtherMEDCOST
NC8914885Medicaid
NCE51660Medicare UPIN
SC44365OtherMEDCOST