Provider Demographics
NPI:1467944041
Name:ISON, ELYSIA (OD)
Entity Type:Individual
Prefix:
First Name:ELYSIA
Middle Name:
Last Name:ISON
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 1:825 POLLARD RD
Mailing Address - Street 2:STE 208
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-1435
Mailing Address - Country:US
Mailing Address - Phone:505-368-6001
Mailing Address - Fax:
Practice Address - Street 1:US HWY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-6001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34112TLG152W00000X
COOPT.0003406152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty