Provider Demographics
NPI:1306857446
Name:BENNETT, JOHN DIETER (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DIETER
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 1:4645 SAMUELL BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-6826
Mailing Address - Country:US
Mailing Address - Phone:214-275-7393
Mailing Address - Fax:
Practice Address - Street 1:4645 SAMUELL BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-6826
Practice Address - Country:US
Practice Address - Phone:214-905-0595
Practice Address - Fax:214-905-0979
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH97922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX039795201Medicaid
TX81X151Medicare ID - Type Unspecified
TX039795201Medicaid