Provider Demographics
NPI:1558777656
Name:BENEDICT, MICHAEL JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:BENEDICT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2445 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3257
Mailing Address - Country:US
Mailing Address - Phone:217-222-9207
Mailing Address - Fax:217-222-9205
Practice Address - Street 1:520 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-1937
Practice Address - Country:US
Practice Address - Phone:573-581-7007
Practice Address - Fax:573-581-1592
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074559152W00000X
MO2014031862152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1558777656Medicaid
IA1558777656Medicaid