Provider Demographics
NPI:1669599403
Name:BENJAMIN, MARK PAUL (OPTOMETRIST OD DEGRE)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:PAUL
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:OPTOMETRIST OD DEGRE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 WEST 89TH PLACE
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410
Mailing Address - Country:US
Mailing Address - Phone:219-795-1356
Mailing Address - Fax:
Practice Address - Street 1:759 EAST 81ST AVENUE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410
Practice Address - Country:US
Practice Address - Phone:219-736-0013
Practice Address - Fax:219-769-8842
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002462A152W00000X
IN18002462B152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy