Provider Demographics
NPI:1558385666
Name:BENNETT, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:203 S WESTERN AVE
Mailing Address - Street 2:C/O: CREDENTIALING
Mailing Address - City:TONASKET
Mailing Address - State:WA
Mailing Address - Zip Code:98855-8803
Mailing Address - Country:US
Mailing Address - Phone:509-486-3144
Mailing Address - Fax:509-486-3176
Practice Address - Street 1:203 S WESTERN AVE
Practice Address - Street 2:C/O: CREDENTIALING
Practice Address - City:TONASKET
Practice Address - State:WA
Practice Address - Zip Code:98855
Practice Address - Country:US
Practice Address - Phone:509-486-2151
Practice Address - Fax:509-486-3176
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00020703207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1558385666Medicaid