Provider Demographics
NPI:1336479724
Name:BENHAM, KEVIN L (10665TG OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:BENHAM
Suffix:
Gender:M
Credentials:10665TG OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 STATE HIGHWAY 6
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845
Mailing Address - Country:US
Mailing Address - Phone:979-321-6565
Mailing Address - Fax:979-321-6566
Practice Address - Street 1:4321 STATE HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845
Practice Address - Country:US
Practice Address - Phone:979-321-6565
Practice Address - Fax:979-321-6566
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7932TG152W00000X
TX7392TG152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X
TX10665TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy