Provider Demographics
NPI:1679614846
Name:BENCHO, STEPHEN JR (OD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:BENCHO
Suffix:JR
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 1:2733 KEITH ST NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-3706
Mailing Address - Country:US
Mailing Address - Phone:423-559-0129
Mailing Address - Fax:423-559-0129
Practice Address - Street 1:2733 KEITH ST NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-3706
Practice Address - Country:US
Practice Address - Phone:423-559-0129
Practice Address - Fax:423-559-0129
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1191152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U12156Medicare UPIN
TN0618670001Medicare ID - Type Unspecified