Provider Demographics
NPI:1316913718
Name:BENNETT, JEFFREY R (OD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:BENNETT
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 1:1544 GREENVIEW DR SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-4322
Mailing Address - Country:US
Mailing Address - Phone:507-287-2711
Mailing Address - Fax:
Practice Address - Street 1:1544 GREENVIEW DR SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-4322
Practice Address - Country:US
Practice Address - Phone:507-287-2711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2298152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00728901OtherRAILROAD MEDICARE
MN671825600Medicaid
MN671825600Medicaid
MN410002836Medicare PIN