Provider Demographics
NPI:1013991165
Name:BENNETT, DONALD WALTER (OD MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:WALTER
Last Name:BENNETT
Suffix:
Gender:M
Credentials:OD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1935 BLUEGRASS AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-1179
Mailing Address - Country:US
Mailing Address - Phone:502-895-0040
Mailing Address - Fax:502-361-4488
Practice Address - Street 1:1935 BLUEGRASS AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1179
Practice Address - Country:US
Practice Address - Phone:502-895-0040
Practice Address - Fax:502-361-4488
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23368207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64233687Medicaid
IN200101170Medicaid
IN200101170Medicaid
KY1454001Medicare ID - Type Unspecified
IN331420AMedicare ID - Type Unspecified
C76151Medicare UPIN
KY0365501Medicare ID - Type Unspecified