Provider Demographics
NPI:1992770416
Name:BENVENUTO, PETER B (OD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:B
Last Name:BENVENUTO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:2817 BARTLETT BLVD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-4529
Practice Address - Country:US
Practice Address - Phone:901-371-0770
Practice Address - Fax:901-371-9892
Is Sole Proprietor?:No
Enumeration Date:2006-02-19
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD 555 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3595626Medicare ID - Type Unspecified