Healthcare Provider Details

I. General information

NPI: 1255435798
Provider Name (Legal Business Name): JOHN BENNET II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26040 DETROIT RD SUITE 7
WESTLAKE OH
44145-2481
US

IV. Provider business mailing address

26040 DETROIT RD SUITE 7
WESTLAKE OH
44145-2481
US

V. Phone/Fax

Practice location:
  • Phone: 440-871-1717
  • Fax: 440-871-3098
Mailing address:
  • Phone: 440-871-1717
  • Fax: 440-871-3098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35 056333
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: