Provider Demographics
NPI:1649274986
Name:BENTZ, JEROME WAYNE (MD)
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:WAYNE
Last Name:BENTZ
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:PO BOX 818
Mailing Address - Street 2:
Mailing Address - City:PLATTE
Mailing Address - State:SD
Mailing Address - Zip Code:57369-0818
Mailing Address - Country:US
Mailing Address - Phone:605-337-1501
Mailing Address - Fax:605-337-3360
Practice Address - Street 1:601 E 7TH ST
Practice Address - Street 2:
Practice Address - City:PLATTE
Practice Address - State:SD
Practice Address - Zip Code:57369-2123
Practice Address - Country:US
Practice Address - Phone:605-337-1501
Practice Address - Fax:605-337-3360
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5602594Medicaid
SD5602593Medicaid
SD5602593Medicaid
SDA01869Medicare UPIN