Provider Demographics
NPI:1043527245
Name:BENTON, MARK DAVID
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:BENTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ATWELL RD
Mailing Address - Street 2:EYE CLINIC
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-1301
Mailing Address - Country:US
Mailing Address - Phone:607-547-3142
Mailing Address - Fax:607-547-3192
Practice Address - Street 1:1 ATWELL RD
Practice Address - Street 2:EYE CLINIC
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1301
Practice Address - Country:US
Practice Address - Phone:607-547-3142
Practice Address - Fax:607-547-3192
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC 3586156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician