Provider Demographics
NPI:1851720429
Name:BENNETT, KURT JACOB (OD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:JACOB
Last Name:BENNETT
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 1:14428 WHITE BIRCH VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2416
Mailing Address - Country:US
Mailing Address - Phone:812-606-9500
Mailing Address - Fax:
Practice Address - Street 1:14428 WHITE BIRCH VALLEY LN
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2416
Practice Address - Country:US
Practice Address - Phone:812-606-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2391152W00000X
MO2013032691152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist