Provider Demographics
NPI:1003848433
Name:BENEDICT, EUGENE GEORGE (OD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:GEORGE
Last Name:BENEDICT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 E FRONT ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-1499
Mailing Address - Country:US
Mailing Address - Phone:269-695-9011
Mailing Address - Fax:269-695-2251
Practice Address - Street 1:802 E FRONT ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-1499
Practice Address - Country:US
Practice Address - Phone:269-695-9011
Practice Address - Fax:269-695-2251
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002243152W00000X
IN18001440A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5014457Medicaid
0140430001Medicare NSC
MI5014457Medicaid