Provider Demographics
NPI:1114300472
Name:KONYNENBELT, BENJAMIN JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JOHN
Last Name:KONYNENBELT
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:2551 DREW ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-2839
Practice Address - Country:US
Practice Address - Phone:727-791-1214
Practice Address - Fax:844-766-9698
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3237152WV0400X
FLOPC5272152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019087700Medicaid