Healthcare Provider Details

I. General information

NPI: 1083901219
Provider Name (Legal Business Name): ALEX J BENNER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S 17TH ST
BLAIR NE
68008-2055
US

IV. Provider business mailing address

201 N MAIN ST BOX 399
DENISON IA
51442-1373
US

V. Phone/Fax

Practice location:
  • Phone: 402-426-2119
  • Fax: 402-426-2120
Mailing address:
  • Phone: 712-263-2020
  • Fax: 712-263-4053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number002518
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: