Provider Demographics
NPI:1437715091
Name:AVERY, ELIZABETH GRACE (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:GRACE
Last Name:AVERY
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 1:322 N DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2233
Mailing Address - Country:US
Mailing Address - Phone:937-376-4055
Mailing Address - Fax:937-376-3969
Practice Address - Street 1:322 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2233
Practice Address - Country:US
Practice Address - Phone:937-376-4055
Practice Address - Fax:937-376-3969
Is Sole Proprietor?:No
Enumeration Date:2019-05-19
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.006782152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist