Provider Demographics
NPI:1245303213
Name:BENNETT, CHERYL L (OD)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:L
Last Name:BENNETT
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 1:28 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-1740
Mailing Address - Country:US
Mailing Address - Phone:681-892-0393
Mailing Address - Fax:681-892-0299
Practice Address - Street 1:28 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847
Practice Address - Country:US
Practice Address - Phone:681-892-0393
Practice Address - Fax:681-892-0299
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV984 D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3102000000Medicaid
WV4124081Medicare ID - Type Unspecified
U81613Medicare UPIN
WV0693170002Medicare NSC