Provider Demographics
NPI:1336766914
Name:STEVEN P. BENNETT, OD
Entity Type:Organization
Organization Name:STEVEN P. BENNETT, OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE BILLING
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:PINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-724-2517
Mailing Address - Street 1:PO BOX 512
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IN
Mailing Address - Zip Code:46733-0512
Mailing Address - Country:US
Mailing Address - Phone:260-724-2517
Mailing Address - Fax:260-724-7009
Practice Address - Street 1:1401 N 13TH ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IN
Practice Address - Zip Code:46733-3139
Practice Address - Country:US
Practice Address - Phone:260-724-2517
Practice Address - Fax:260-724-7009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100053170AMedicaid