Provider Demographics
NPI:1366239899
Name:BENNIE, JUSTIN GORDON (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:GORDON
Last Name:BENNIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14091 MERCI AVE
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-5586
Mailing Address - Country:US
Mailing Address - Phone:586-295-7031
Mailing Address - Fax:
Practice Address - Street 1:4717 SAINT ANTOINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1423
Practice Address - Country:US
Practice Address - Phone:313-577-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program