Healthcare Provider Details

I. General information

NPI: 1508968777
Provider Name (Legal Business Name): D. JOHN BENNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DARRELL JOHN NOREN BENNETT

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W CENTER STREET
SPANISH FORK UT
84660
US

IV. Provider business mailing address

325 W CENTER STREET
SPANISH FORK UT
84660
US

V. Phone/Fax

Practice location:
  • Phone: 801-798-7301
  • Fax: 801-798-8513
Mailing address:
  • Phone: 801-798-7301
  • Fax: 801-798-8513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number187592-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: