Provider Demographics
NPI:1073734794
Name:BENNETT, JONATHAN CHRISTOPHER (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:CHRISTOPHER
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 42210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85080-2210
Mailing Address - Country:US
Mailing Address - Phone:623-266-7770
Mailing Address - Fax:623-322-4639
Practice Address - Street 1:424 S 56TH ST STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-2177
Practice Address - Country:US
Practice Address - Phone:602-685-5166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0600003440207ZP0102X
MI4301504318207ZP0102X
IN99058473A207ZP0102X
AZ67958207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology