Provider Demographics
NPI:1417028051
Name:ELLENDER, ELIZABETH ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANN
Last Name:ELLENDER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 MOUNT RUSHMORE RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-4591
Mailing Address - Country:US
Mailing Address - Phone:605-348-7401
Mailing Address - Fax:605-348-9773
Practice Address - Street 1:1601 MOUNT RUSHMORE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4591
Practice Address - Country:US
Practice Address - Phone:605-348-7401
Practice Address - Fax:605-348-9773
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDT572152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDU56566Medicare UPIN
SD40069Medicare ID - Type Unspecified