Provider Demographics
NPI:1871955435
Name:BENNETT, MARK RICHARD JR
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-1526
Mailing Address - Country:US
Mailing Address - Phone:563-822-1435
Mailing Address - Fax:563-822-1436
Practice Address - Street 1:709 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-1526
Practice Address - Country:US
Practice Address - Phone:563-822-1435
Practice Address - Fax:563-822-1436
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD131948367500000X
IA131948390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program