Provider Demographics
NPI:1205065935
Name:BENZONI, JACLYN ANNE (OD)
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:ANNE
Last Name:BENZONI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2126 MERRICK MALL
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-3626
Mailing Address - Country:US
Mailing Address - Phone:516-546-3227
Mailing Address - Fax:516-546-4923
Practice Address - Street 1:2126 MERRICK MALL
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3626
Practice Address - Country:US
Practice Address - Phone:516-546-3227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007403-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400045238Medicare PIN