Provider Demographics
NPI:1710930755
Name:BENNINGTON, JUDITH A (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:BENNINGTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 BEASER AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-3608
Mailing Address - Country:US
Mailing Address - Phone:715-682-0363
Mailing Address - Fax:715-682-9638
Practice Address - Street 1:2111 BEASER AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3608
Practice Address - Country:US
Practice Address - Phone:715-682-0363
Practice Address - Fax:715-682-9638
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21223207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30133400Medicaid
WI30133400Medicaid
B84693Medicare UPIN