Provider Demographics
NPI:1972501385
Name:BENNETT, MARY JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JEAN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:M
Other - Middle Name:JEAN
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2035 ZUMBEHL RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-2723
Mailing Address - Country:US
Mailing Address - Phone:636-946-1176
Mailing Address - Fax:636-946-1533
Practice Address - Street 1:2035 ZUMBEHL RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-2723
Practice Address - Country:US
Practice Address - Phone:636-946-1176
Practice Address - Fax:636-946-1533
Is Sole Proprietor?:No
Enumeration Date:2005-07-09
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02492152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU13461Medicare UPIN
MO002009251Medicare ID - Type Unspecified