Provider Demographics
NPI:1316930670
Name:BENNETT, STEVEN I (OD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:I
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 1:117 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-1902
Mailing Address - Country:US
Mailing Address - Phone:734-665-5306
Mailing Address - Fax:734-930-2383
Practice Address - Street 1:117 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-1902
Practice Address - Country:US
Practice Address - Phone:734-665-5306
Practice Address - Fax:734-930-2383
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002604152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2675077Medicaid
MISB002604OtherBCBS MICHIGAN
MISB002604OtherBCBS MICHIGAN
MI2675077Medicaid