MEDICARE: DR. KURT JACOB 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	TA2391	MD
2	152W00000X	Optometrist	2013032691	MO

General Provider Information

NPI Number	:	1851720429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KURT JACOB BENNETT O.D

Provider Business Mailing Address
First Line	:	14428 WHITE BIRCH VALLEY LN
Second Line	:
City	:	CHESTERFIELD
State	:	MO
Zip	:	63017-2416
Country	:	US
Telephone Number	:	812-606-9500
Fax Number	:

Provider Business Practice Location Address
First Line	:	14428 WHITE BIRCH VALLEY LN
Second Line	:
City	:	CHESTERFIELD
State	:	MO
Zip	:	63017-2416
Country	:	US
Telephone Number	:	812-606-9500
Fax Number	:

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

Provider Enumeration Date	:	11/05/2013
Last Update Date	:	11/05/2013

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