Provider Demographics
NPI:1215375480
Name:CRIDER, BENJAMIN JOHNSON (OD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JOHNSON
Last Name:CRIDER
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:571-223-6780
Practice Address - Street 1:105 GRAND CENTRAL BLVD STE 110
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4148
Practice Address - Country:US
Practice Address - Phone:912-450-9200
Practice Address - Fax:912-450-9201
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003372152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000831910OtherANTHEM
INM141161001Medicare PIN
ININ1942012Medicare PIN
IN89406012Medicare PIN