Provider Demographics
NPI:1376146373
Name:BENEDICT, CODY MICHAEL (OD)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:MICHAEL
Last Name:BENEDICT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:CODY
Other - Middle Name:M
Other - Last Name:BENEDICT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:603 OAK ST W UNIT 1
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:WI
Mailing Address - Zip Code:54837-8902
Mailing Address - Country:US
Mailing Address - Phone:715-566-4160
Mailing Address - Fax:
Practice Address - Street 1:110 EVERGREEN SQ SW
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-2000
Practice Address - Country:US
Practice Address - Phone:320-629-7262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3756152W00000X
WI3652-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist