Provider Demographics
NPI:1124010889
Name:BENNETT, JOHN DAVID (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-4104
Mailing Address - Country:US
Mailing Address - Phone:515-271-1731
Mailing Address - Fax:515-271-1692
Practice Address - Street 1:3200 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-4104
Practice Address - Country:US
Practice Address - Phone:515-271-1731
Practice Address - Fax:515-271-1692
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00653213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0172239Medicaid
U70200Medicare UPIN
IA0172239Medicaid