Provider Demographics
NPI:1164433876
Name:ELCYZYN, TIM E (OD)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:E
Last Name:ELCYZYN
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 1:3805 W 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-4774
Mailing Address - Country:US
Mailing Address - Phone:870-536-3100
Mailing Address - Fax:870-536-3100
Practice Address - Street 1:3805 W 28TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-4774
Practice Address - Country:US
Practice Address - Phone:870-536-3100
Practice Address - Fax:870-536-3100
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2569152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00362854OtherRAILROAD MEDICARE PIN
P00362854OtherRAILROAD MEDICARE PIN
49956Medicare PIN