Provider Demographics
NPI:1083800080
Name:BENNETT, JAMIE A (OD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:A
Last Name:BENNETT
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 1:401 E SILAS ST
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003-3611
Mailing Address - Country:US
Mailing Address - Phone:918-336-4068
Mailing Address - Fax:
Practice Address - Street 1:401 E SILAS ST
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-3611
Practice Address - Country:US
Practice Address - Phone:918-336-4068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1189152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU11159Medicare UPIN
OK248321002Medicare PIN