Provider Demographics
NPI:1235866500
Name:ELM, ANDREW LEIGH (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:LEIGH
Last Name:ELM
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 1:1869 RAINBOW AVE
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-1721
Mailing Address - Country:US
Mailing Address - Phone:920-246-9353
Mailing Address - Fax:
Practice Address - Street 1:173 7TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-1804
Practice Address - Country:US
Practice Address - Phone:212-627-4488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009634152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist