MEDICARE: DR. JASON DAVID BENNETT O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901004375	MI

General Provider Information

NPI Number	:	1447264551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON DAVID BENNETT O.D.

Provider Business Mailing Address
First Line	:	4850 ENCORE BLVD
Second Line	:
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-6013
Country	:	US
Telephone Number	:	989-772-1704
Fax Number	:	989-773-9406

Provider Business Practice Location Address
First Line	:	4850 ENCORE BLVD
Second Line	:
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-6013
Country	:	US
Telephone Number	:	989-772-1704
Fax Number	:	989-773-9406

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	06/30/2014

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