Provider Demographics
NPI:1497850325
Name:BENNETT, JONATHAN IAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:IAN
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 1:300 N EUCLID ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1623
Mailing Address - Country:US
Mailing Address - Phone:714-888-6860
Mailing Address - Fax:714-888-6867
Practice Address - Street 1:300 N EUCLID ST
Practice Address - Street 2:SUITE A
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1623
Practice Address - Country:US
Practice Address - Phone:714-888-6860
Practice Address - Fax:714-888-6867
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4301213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4301OtherSTATE LICENSE