Provider Demographics
NPI:1508968777
Name:BENNETT, D. JOHN
Entity Type:Individual
Prefix:
First Name:D. JOHN
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DARRELL JOHN
Other - Middle Name:NOREN
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:325 W CENTER STREET
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660
Mailing Address - Country:US
Mailing Address - Phone:801-798-7301
Mailing Address - Fax:801-798-8513
Practice Address - Street 1:325 W CENTER STREET
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660
Practice Address - Country:US
Practice Address - Phone:801-798-7301
Practice Address - Fax:801-798-8513
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT187592-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD0463Medicaid
UTD0463Medicaid