Provider Demographics
NPI:1134295280
Name:CONTILLO, ELISSA M (OD)
Entity Type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:M
Last Name:CONTILLO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 ATWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-5322
Mailing Address - Country:US
Mailing Address - Phone:401-421-4821
Mailing Address - Fax:401-421-0928
Practice Address - Street 1:671 ATWOOD AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-5322
Practice Address - Country:US
Practice Address - Phone:401-421-4821
Practice Address - Fax:401-421-0928
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG00558152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9007907Medicaid
RI0208090001Medicare NSC
RIT79193Medicare UPIN