Provider Demographics
NPI:1255304259
Name:BENDER, JAN (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:BENDER
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 1:6449 38TH AVE N
Mailing Address - Street 2:SUITE G4
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1655
Mailing Address - Country:US
Mailing Address - Phone:727-347-2557
Mailing Address - Fax:727-345-8972
Practice Address - Street 1:6449 38TH AVE N
Practice Address - Street 2:SUITE G4
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1655
Practice Address - Country:US
Practice Address - Phone:727-347-2557
Practice Address - Fax:727-345-8972
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0055667208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056530000Medicaid
FL056530000Medicaid