Provider Demographics
NPI:1427073014
Name:DAUGHERTY, BENNA KAYE (OD)
Entity type:Individual
Prefix:DR
First Name:BENNA
Middle Name:KAYE
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:BENNA
Other - Middle Name:KAYE
Other - Last Name:SISK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-0488
Mailing Address - Country:US
Mailing Address - Phone:618-253-7057
Mailing Address - Fax:618-252-1632
Practice Address - Street 1:960 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2637
Practice Address - Country:US
Practice Address - Phone:618-253-7057
Practice Address - Fax:618-252-1632
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046-007542Medicaid
IL046007542Medicaid
IL046-007542Medicaid
ILL08225Medicare PIN
IL0185380001Medicare NSC