Healthcare Provider Details

I. General information

NPI: 1851328074
Provider Name (Legal Business Name): JOHN MELTON BENNETT MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 PAULINE DR
BEREA KY
40403-8889
US

IV. Provider business mailing address

1101 VETERANS DR BEREA CBOC
LEXINGTON KY
40502-2235
US

V. Phone/Fax

Practice location:
  • Phone: 859-233-4511
  • Fax:
Mailing address:
  • Phone: 859-233-4511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30690
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number30690
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number30690
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number30690
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number30690
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: