Provider Demographics
NPI:1518167550
Name:BENNETT, JACK DAVID (MD)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:DAVID
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 1:617 S MARKET ST
Mailing Address - Street 2:#2
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-1654
Mailing Address - Country:US
Mailing Address - Phone:740-941-1859
Mailing Address - Fax:740-941-1859
Practice Address - Street 1:617 S MARKET ST
Practice Address - Street 2:#2
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1654
Practice Address - Country:US
Practice Address - Phone:740-941-1859
Practice Address - Fax:740-941-1859
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067134208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0986429Medicaid
F92648Medicare UPIN