Provider Demographics
NPI:1003944968
Name:BENDE, LORI JOHNSON (OD)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:JOHNSON
Last Name:BENDE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4009 GOVERNOR DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-2522
Mailing Address - Country:US
Mailing Address - Phone:858-453-0444
Mailing Address - Fax:
Practice Address - Street 1:4009 GOVERNOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-2522
Practice Address - Country:US
Practice Address - Phone:858-453-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10611T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0106110Medicaid
CA50322OtherAVP SAFEGURAD PROVIDER NU
CA13089OtherMEDICAL EYE SERVICES PROV
CAW18234Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAWOP10611EMedicare ID - Type UnspecifiedPPIN
CASD0106110Medicaid