Provider Demographics
NPI:1871596452
Name:BENSON, MARK ALLEN (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:BENSON
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 1:800 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742-1329
Mailing Address - Country:US
Mailing Address - Phone:563-659-3999
Mailing Address - Fax:563-659-2966
Practice Address - Street 1:800 6TH AVE
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:IA
Practice Address - Zip Code:52742-1329
Practice Address - Country:US
Practice Address - Phone:563-659-3999
Practice Address - Fax:563-659-2966
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02006152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2101030Medicaid
IA55696OtherWELLMAR BCBS
2062018OtherFIRST HEALTH
IA410047150Medicare PIN
2062018OtherFIRST HEALTH
43686Medicare UPIN
IAI3188Medicare PIN