Provider Demographics
NPI:1558454553
Name:BENNETT, MICHAEL J (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:BENNETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9309 GLACIER HWY STE A103
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-9300
Mailing Address - Country:US
Mailing Address - Phone:907-789-3175
Mailing Address - Fax:907-789-1778
Practice Address - Street 1:9309 GLACIER HWY STE A103
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-9300
Practice Address - Country:US
Practice Address - Phone:907-789-3175
Practice Address - Fax:907-789-1778
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK188152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK152386Medicare PIN
AKT30546Medicare UPIN