Provider Demographics
NPI:1134124928
Name:ELLEN, LOUIS P (OD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:P
Last Name:ELLEN
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 1:1401 HARRODSBURG RD
Mailing Address - Street 2:STE B75
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1724
Mailing Address - Country:US
Mailing Address - Phone:859-278-9393
Mailing Address - Fax:859-278-0923
Practice Address - Street 1:540 JETT DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-9622
Practice Address - Country:US
Practice Address - Phone:606-666-9393
Practice Address - Fax:606-666-4131
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1500DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77000404Medicaid
T46198Medicare UPIN
KY0268612Medicare PIN