Provider Demographics
NPI:1205829629
Name:ELSTON, PHILLIP R (OD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:R
Last Name:ELSTON
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 1:3241 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3849
Mailing Address - Country:US
Mailing Address - Phone:336-413-8843
Mailing Address - Fax:312-949-7660
Practice Address - Street 1:970 S OLD WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6726
Practice Address - Country:US
Practice Address - Phone:248-369-3300
Practice Address - Fax:248-369-3275
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009787152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009787Medicaid