Provider Demographics
NPI:1689680563
Name:BENNETT, KERRY D (DO)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:D
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6280 S 625 W
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-8972
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 W BETHEL AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5407
Practice Address - Country:US
Practice Address - Phone:765-284-7738
Practice Address - Fax:765-213-3713
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001168A207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200043532OtherRR MEDICARE
IN000000209731OtherANTHEM PIN
IN200359010Medicaid
IN000000209731OtherANTHEM PIN
IN200043532OtherRR MEDICARE