Provider Demographics
NPI:1134311764
Name:ELLERBROCK-HEITZMAN, JOY MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:JOY
Middle Name:MARIE
Last Name:ELLERBROCK-HEITZMAN
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:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:CONTINENTAL
Mailing Address - State:OH
Mailing Address - Zip Code:45831-0042
Mailing Address - Country:US
Mailing Address - Phone:419-596-3062
Mailing Address - Fax:419-596-3064
Practice Address - Street 1:301 E STATE ROUTE 613
Practice Address - Street 2:
Practice Address - City:CONTINENTAL
Practice Address - State:OH
Practice Address - Zip Code:45831-9133
Practice Address - Country:US
Practice Address - Phone:419-596-3062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5716/T2630152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00904130Medicare PIN
OH6210450001Medicare NSC
OH4256881Medicare PIN