Provider Demographics
NPI:1477649614
Name:BENNETT, LINDA MAE (OD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:MAE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:M
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:231 BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478
Mailing Address - Country:US
Mailing Address - Phone:617-484-1414
Mailing Address - Fax:617-489-1957
Practice Address - Street 1:231 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478
Practice Address - Country:US
Practice Address - Phone:617-484-1414
Practice Address - Fax:617-489-1957
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA2870152W00000X
MA2870152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAT59393Medicare UPIN
MA404358Medicare ID - Type Unspecified