Provider Demographics
NPI:1902919582
Name:BENZINGER, BART ANDREW (OD)
Entity Type:Individual
Prefix:
First Name:BART
Middle Name:ANDREW
Last Name:BENZINGER
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 1:4120 VANCE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6745
Mailing Address - Country:US
Mailing Address - Phone:260-484-0864
Mailing Address - Fax:
Practice Address - Street 1:402 W. PLAZA DR
Practice Address - Street 2:WAL-MART VISION CENTER
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725
Practice Address - Country:US
Practice Address - Phone:260-244-7620
Practice Address - Fax:260-244-7870
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002907A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U72737Medicare UPIN
225930Medicare ID - Type UnspecifiedNON-PARTICIPATING