Provider Demographics
NPI:1669574588
Name:BENNETT, RONALD GORDON (MD)
Entity type:Individual
Prefix:
First Name:RONALD
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 1:2475 N PARK DR
Mailing Address - Street 2:STE 10
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-2200
Mailing Address - Country:US
Mailing Address - Phone:812-373-7940
Mailing Address - Fax:812-378-9518
Practice Address - Street 1:2475 N PARK DR
Practice Address - Street 2:STE 10
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-2200
Practice Address - Country:US
Practice Address - Phone:812-373-7940
Practice Address - Fax:812-378-9518
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN234390Medicare ID - Type Unspecified
IND94433Medicare UPIN