Provider Demographics
NPI:1558395806
Name:BENIGNO, KIMBERLY R (OD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:BENIGNO
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 1:1720A MEDICAL PARK DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2129
Mailing Address - Country:US
Mailing Address - Phone:228-396-5185
Mailing Address - Fax:228-396-5186
Practice Address - Street 1:1720A MEDICAL PARK DR
Practice Address - Street 2:SUITE 330
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2129
Practice Address - Country:US
Practice Address - Phone:228-396-5185
Practice Address - Fax:228-396-5186
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0880093Medicaid
MS94170OtherTPA #
MS0880093Medicaid
MS94170OtherTPA #