Provider Demographics
NPI:1740240118
Name:BENNETT, GORDON L (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:L
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 1:3800 EMBASSY PKWY
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44333-8387
Mailing Address - Country:US
Mailing Address - Phone:330-971-7571
Mailing Address - Fax:330-255-5093
Practice Address - Street 1:3800 EMBASSY PKWY
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44333-8387
Practice Address - Country:US
Practice Address - Phone:330-971-7571
Practice Address - Fax:330-255-5093
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-051526207X00000X
OH35.051526207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0823934Medicaid
OH200036198OtherRAIL ROAD MEDICARE
OH0569579Medicare PIN