Provider Demographics
NPI:1679627301
Name:BENNETT, EUGENE (OD)
Entity type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4824 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1312
Mailing Address - Country:US
Mailing Address - Phone:903-581-2020
Mailing Address - Fax:903-509-1492
Practice Address - Street 1:4824 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1312
Practice Address - Country:US
Practice Address - Phone:903-581-2020
Practice Address - Fax:903-509-1492
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX751573775OtherTAX ID
TX019677601Medicaid
TX751573775OtherTAX ID
TX82046EMedicare ID - Type UnspecifiedPROFORMING PROVIDER ID
TX00E60MMedicare ID - Type UnspecifiedPROVIDER ID