Provider Demographics
NPI:1164416376
Name:ELLINGER, STEVEN S (OD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:S
Last Name:ELLINGER
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 1:1612 E. CENTRE AVE.
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002
Mailing Address - Country:US
Mailing Address - Phone:269-329-1030
Mailing Address - Fax:269-329-0966
Practice Address - Street 1:1612 E. CENTRE AVE.
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002
Practice Address - Country:US
Practice Address - Phone:269-329-1030
Practice Address - Fax:269-329-0966
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003721152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM60130009Medicare PIN
MIU73526Medicare UPIN
MI5599300001Medicare NSC
MIOP28110Medicare PIN