Provider Demographics
NPI:1407825490
Name:BENYO, MICHAEL JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:BENYO
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:570-887-3236
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000948152W00000X
NYTUV004754-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA410043463OtherRR MEDICARE PIN
PA0011014560001Medicaid
NY01054920Medicaid
NYCC8362OtherRR MEDICARE GROUP
PAGU039785OtherMEDICARE GROUP
NYP00324442OtherRR MEDICARE PIN
PACC9269OtherRR MEDICARE GROUP
NYCC8362OtherRR MEDICARE GROUP
PA410043463OtherRR MEDICARE PIN
PAGU039785OtherMEDICARE GROUP