Provider Demographics
NPI:1285208546
Name:BENNETT, ALEXANDER (OD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
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 1:133 S LOS ROBLES AVE UNIT 508
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-5824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14425 CHASE ST
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-3017
Practice Address - Country:US
Practice Address - Phone:818-891-6711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003672152W00000X
CAOPT35541-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty