Provider Demographics
NPI:1114075645
Name:EILENFELDT, PAMELA JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:JEAN
Last Name:EILENFELDT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:JEAN
Other - Last Name:MIKULECKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-693-9542
Practice Address - Street 1:1265 N HENDERSON ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1510
Practice Address - Country:US
Practice Address - Phone:309-343-7799
Practice Address - Fax:309-343-7934
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008618152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008618Medicaid
IL046008618Medicaid