Provider Demographics
NPI:1346892627
Name:MASSEY, BENJAMIN EDWARD (OD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:EDWARD
Last Name:MASSEY
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 1:1422 DILLER RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3430 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5732
Practice Address - Country:US
Practice Address - Phone:228-875-6658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1005152W00000X
GAOPT003183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist