Provider Demographics
NPI:1780656660
Name:BENNION, SCOTT W (OD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:W
Last Name:BENNION
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 1:23714 222ND PL SE STE B
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-5800
Mailing Address - Country:US
Mailing Address - Phone:425-432-1206
Mailing Address - Fax:425-413-4465
Practice Address - Street 1:23714 222ND PL SE STE B
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038
Practice Address - Country:US
Practice Address - Phone:425-432-1206
Practice Address - Fax:425-413-4465
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA1115TX152WC0802X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2032076Medicaid
WA1780656660Medicare NSC
T01915Medicare UPIN
WA8860948Medicare PIN