Provider Demographics
NPI:1346228665
Name:BENNEHOFF, ERICA DANIELLE (OD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:DANIELLE
Last Name:BENNEHOFF
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6220 OLD DOBBIN LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5812
Mailing Address - Country:US
Mailing Address - Phone:443-896-0710
Mailing Address - Fax:
Practice Address - Street 1:7550 TEAGUE RD
Practice Address - Street 2:SUITE 114
Practice Address - City:HANOVER
Practice Address - State:MD
Practice Address - Zip Code:21076-1339
Practice Address - Country:US
Practice Address - Phone:410-799-8067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009555152W00000X
MDTA2031152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK09684Medicare UPIN