Provider Demographics
NPI:1164470761
Name:BENNETT, JOHN CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
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 1:500 W 3RD AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1985
Mailing Address - Country:US
Mailing Address - Phone:229-312-5839
Mailing Address - Fax:229-312-5853
Practice Address - Street 1:425 W 3RD AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1941
Practice Address - Country:US
Practice Address - Phone:229-312-0707
Practice Address - Fax:229-312-0705
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057581208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA057581OtherSTATE MEDICAL LICENSE
GA182727627DMedicaid
GA202I027275Medicare PIN