Provider Demographics
NPI:1396185757
Name:BENNICOFF, ERIC PAUL
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:PAUL
Last Name:BENNICOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 BUSHKILL CENTER RD
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:PA
Mailing Address - Zip Code:18064-9486
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 MAIN ST
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-2575
Practice Address - Country:US
Practice Address - Phone:570-476-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002823152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist