Provider Demographics
NPI:1952449357
Name:BENNETT, GEOFFREY C (OD)
Entity Type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:C
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 1:5076 ERICKSON RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-2732
Mailing Address - Country:US
Mailing Address - Phone:218-591-5252
Mailing Address - Fax:
Practice Address - Street 1:12080 HIGHWAY 169 W
Practice Address - Street 2:WAL MART VISION CENTER #2937
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-3035
Practice Address - Country:US
Practice Address - Phone:218-262-3853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2175152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN750025400Medicaid
MNT19565Medicare UPIN
MN419000948Medicare PIN