Provider Demographics
NPI:1922273754
Name:EUGENE D. BENNETT
Entity type:Organization
Organization Name:EUGENE D. BENNETT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:903-581-2020
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX019677601Medicaid
TX82046EOtherMEDICARE
TX00E60MOtherMEDICARE
TX1679627301OtherNPI
TXW27902Medicare UPIN