Healthcare Provider Details

I. General information

NPI: 1982714564
Provider Name (Legal Business Name): EDWARD STRACHAN BENNETT OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7840 NATURAL BRIDGE BLVD PATIENT CARE CENTER
SAINT LOUIS MO
63121
US

IV. Provider business mailing address

ONE UNIVERSITY BLVD PATIENT CARE CENTER
ST. LOUIS MO
63121
US

V. Phone/Fax

Practice location:
  • Phone: 314-516-5131
  • Fax: 314-516-5507
Mailing address:
  • Phone: 314-516-5131
  • Fax: 314-516-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberT02542
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02542
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: