Provider Demographics
NPI:1467155598
Name:BENNISON, JOHN CHARLES (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:BENNISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 RIVERSIDE DR APT 2
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3344
Mailing Address - Country:US
Mailing Address - Phone:518-878-2765
Mailing Address - Fax:
Practice Address - Street 1:2500 METROHEALTH DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1900
Practice Address - Country:US
Practice Address - Phone:216-778-4486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program