Provider Demographics
NPI:1710971841
Name:BENEDICT, BRUCE E (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:E
Last Name:BENEDICT
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 1:23940 GREY FOX LN
Mailing Address - Street 2:
Mailing Address - City:GRANTSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54840-8551
Mailing Address - Country:US
Mailing Address - Phone:715-463-2459
Mailing Address - Fax:
Practice Address - Street 1:617 S PINE ST
Practice Address - Street 2:
Practice Address - City:GRANTSBURG
Practice Address - State:WI
Practice Address - Zip Code:54840-7935
Practice Address - Country:US
Practice Address - Phone:715-463-2459
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1329-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist