Provider Demographics
NPI:1548598410
Name:BENNETT, JOHN GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GORDON
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 1:1200 WEST AVE
Mailing Address - Street 2:SUITE 825
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139
Mailing Address - Country:US
Mailing Address - Phone:786-370-3917
Mailing Address - Fax:
Practice Address - Street 1:1200 WEST AVE
Practice Address - Street 2:SUITE 825
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-4377
Practice Address - Country:US
Practice Address - Phone:786-370-3917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL48950172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker