Provider Demographics
NPI:1558473868
Name:BENNETT, MICHAEL E (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:BENNETT
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 1:110 E HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-4839
Mailing Address - Country:US
Mailing Address - Phone:405-282-4396
Mailing Address - Fax:405-282-8298
Practice Address - Street 1:110 E HARRISON AVE
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-4839
Practice Address - Country:US
Practice Address - Phone:405-282-4396
Practice Address - Fax:405-282-8298
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100766560AMedicaid
OK244501401Medicare PIN
OKT40357Medicare UPIN