Provider Demographics
NPI:1063571305
Name:NELSON, BENNETT W (OD)
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:W
Last Name:NELSON
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 1:206 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-1331
Mailing Address - Country:US
Mailing Address - Phone:320-253-0365
Mailing Address - Fax:320-253-9401
Practice Address - Street 1:206 DIVISION ST
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1331
Practice Address - Country:US
Practice Address - Phone:320-253-0365
Practice Address - Fax:320-253-9401
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3091152W00000X
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP82012OtherHEALTH PARTNERS
MNXX0531051795OtherPREFERRED ONE
MN453K2NEOtherBLUE CROSS
MNP00416930Medicare PIN
MN453K2NEOtherBLUE CROSS