Provider Demographics
NPI:1124038823
Name:BENNETT, WILLIAM H (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:H
Last Name:BENNETT
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 1:417 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ORRVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44667-1822
Mailing Address - Country:US
Mailing Address - Phone:330-683-3963
Mailing Address - Fax:330-683-3453
Practice Address - Street 1:417 W MARKET ST
Practice Address - Street 2:
Practice Address - City:ORRVILLE
Practice Address - State:OH
Practice Address - Zip Code:44667-1822
Practice Address - Country:US
Practice Address - Phone:330-683-3963
Practice Address - Fax:330-683-3453
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3278152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0128787OtherANTHEM PROVIDER NUMBER
OH0465661OtherPTAN/MEDICARE PROVIDER NUMBER
OH0339842Medicaid
OH341225963OtherMMO PROVIDER NUMBER
OH0339842Medicaid
OH0365990001Medicare NSC
OH0128787OtherANTHEM PROVIDER NUMBER