Provider Demographics
NPI:1861467599
Name:BENNETT, MARK DANIEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DANIEL
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 1:13530 NORTHGATE ESTATES DR STE 200
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-7651
Mailing Address - Country:US
Mailing Address - Phone:719-593-2333
Mailing Address - Fax:719-593-0012
Practice Address - Street 1:13530 NORTHGATE ESTATES DR STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-7651
Practice Address - Country:US
Practice Address - Phone:719-593-2333
Practice Address - Fax:719-593-0012
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1343152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08134397Medicaid
COCO41302Medicare PIN