Provider Demographics
NPI:1093157562
Name:BENNETT, VANESSA ERIN (OD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ERIN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:ERIN
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 S WHEELING AVE
Mailing Address - Street 2:STE 1010
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5649
Mailing Address - Country:US
Mailing Address - Phone:918-584-4433
Mailing Address - Fax:918-748-8707
Practice Address - Street 1:2000 S WHEELING AVE
Practice Address - Street 2:STE 1010
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5649
Practice Address - Country:US
Practice Address - Phone:918-747-3937
Practice Address - Fax:918-748-8707
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2764152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2764OtherLICENSE