Provider Demographics
NPI:1134483191
Name:DANNEBROCK, ELIZABETH ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANN
Last Name:DANNEBROCK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:HETRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:500 DAVISON RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-4021
Mailing Address - Country:US
Mailing Address - Phone:716-434-8063
Mailing Address - Fax:716-434-2845
Practice Address - Street 1:500 DAVISON RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-4021
Practice Address - Country:US
Practice Address - Phone:716-434-8063
Practice Address - Fax:716-434-2845
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007844-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400086920Medicare PIN