Provider Demographics
NPI:1275507725
Name:ELS, DENNIS J (OD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:J
Last Name:ELS
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 1:3454 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-2277
Mailing Address - Country:US
Mailing Address - Phone:618-242-1090
Mailing Address - Fax:618-242-1090
Practice Address - Street 1:3454 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2277
Practice Address - Country:US
Practice Address - Phone:618-242-1090
Practice Address - Fax:618-242-1090
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0046007091152W00000X
MOT02348152W00000X
WI1619035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04600791Medicaid
IL04600791Medicaid
IL607340Medicare PIN
ILT37208Medicare UPIN