Provider Demographics
NPI:1235137878
Name:BENNER, JEFFREY D (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:BENNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6511 DEER POINTE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804
Mailing Address - Country:US
Mailing Address - Phone:410-546-8037
Mailing Address - Fax:410-546-8038
Practice Address - Street 1:6511 DEER POINTE DRIVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804
Practice Address - Country:US
Practice Address - Phone:410-546-8037
Practice Address - Fax:410-546-8038
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0004538207W00000X, 207WX0107X
MDD0035052207WX0107X, 207W00000X
MDD-0035052207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD212101800Medicaid
DE0000468001Medicaid
MD212101800Medicaid
MDE63948Medicare UPIN
MD304L661BMedicare ID - Type Unspecified