Provider Demographics
NPI:1285646661
Name:TIM A BENGTSON O.D., P.C.
Entity Type:Organization
Organization Name:TIM A BENGTSON O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BENGTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-833-4242
Mailing Address - Street 1:820 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-2412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2412
Practice Address - Country:US
Practice Address - Phone:309-833-4242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007904Medicaid
IL0005584005OtherBLUE CROSS BLUE SHIELD
5012480001Medicare NSC
T38622Medicare UPIN
IL046007904Medicaid