Provider Demographics
NPI:1316268618
Name:BENNER, NICHOLAS ANDREW (DO)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ANDREW
Last Name:BENNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2381
Mailing Address - Country:US
Mailing Address - Phone:937-434-2351
Mailing Address - Fax:
Practice Address - Street 1:3555 OLENTANGY RIVER RD
Practice Address - Street 2:STE. 4000
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3912
Practice Address - Country:US
Practice Address - Phone:614-268-2748
Practice Address - Fax:614-263-3376
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34010705207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1316268618OtherNPI