MEDICARE: DR. BENJAMIN JOHNSON CRIDER 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	OPT003372	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000831910	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1215375480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BENJAMIN JOHNSON CRIDER O.D.

Provider Business Mailing Address
First Line	:	1950 OLD GALLOWS RD STE 520
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-3970
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	571-223-6780

Provider Business Practice Location Address
First Line	:	105 GRAND CENTRAL BLVD STE 110
Second Line	:
City	:	POOLER
State	:	GA
Zip	:	31322-4148
Country	:	US
Telephone Number	:	912-450-9200
Fax Number	:	912-450-9201

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

Provider Enumeration Date	:	06/11/2013
Last Update Date	:	09/27/2021

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