Provider Demographics
NPI:1750580163
Name:PAULUS, BENNETT J (OD)
Entity type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:J
Last Name:PAULUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:799 N VINE ST
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830
Mailing Address - Country:US
Mailing Address - Phone:419-435-3323
Mailing Address - Fax:419-435-7834
Practice Address - Street 1:799 N VINE ST
Practice Address - Street 2:FOSTORIA EYECARE INC
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830
Practice Address - Country:US
Practice Address - Phone:419-435-3323
Practice Address - Fax:419-435-7834
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5736152W00000X
OHT2650152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0921926Medicaid
OH0921926Medicaid
OHPA4221761Medicare PIN