Basic Information
| Provider Information | |||||||||
| NPI: | 1114300472 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONYNENBELT | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 8667954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 2551 DREW ST | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337652839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277911214 | ||||||||
| FaxNumber: | 8447669698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WV0400X | 3237 | TN | N | Eye and Vision Services Providers | Optometrist | Vision Therapy | 152W00000X | OPC5272 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 019087700 | 05 | FL | MEDICAID |