Healthcare Provider Details

I. General information

NPI: 1780656660
Provider Name (Legal Business Name): SCOTT W BENNION OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23714 222ND PL SE STE B
MAPLE VALLEY WA
98038
US

IV. Provider business mailing address

23714 222ND PL SE STE B
MAPLE VALLEY WA
98038-5800
US

V. Phone/Fax

Practice location:
  • Phone: 425-432-1206
  • Fax: 425-413-4465
Mailing address:
  • Phone: 425-432-1206
  • Fax: 425-413-4465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberWA1115TX
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberWA1115TX
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberWA1115TX
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: