Provider Demographics
NPI:1609036912
Name:SPECTRUM EYE CARE, PC
Entity Type:Organization
Organization Name:SPECTRUM EYE CARE, PC
Other - Org Name:SPECTRUM EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:719-593-2333
Mailing Address - Street 1:1839 BRIARGATE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3470
Mailing Address - Country:US
Mailing Address - Phone:719-593-2333
Mailing Address - Fax:719-593-0012
Practice Address - Street 1:13530 NORTHGATE ESTATES DR STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-7651
Practice Address - Country:US
Practice Address - Phone:719-593-2333
Practice Address - Fax:719-593-0012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
CO1343152WP0200X, 152WV0400X, 152W00000X
CO1338986332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO89707851Medicaid
COCOB4969Medicare PIN