Provider Demographics
NPI:1518743913
Name:RODRIGUEZ, ELSIE (OD)
Entity Type:Individual
Prefix:
First Name:ELSIE
Middle Name:
Last Name:RODRIGUEZ
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 1:4847 E ROUTE 36
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-9736
Mailing Address - Country:US
Mailing Address - Phone:217-425-3219
Mailing Address - Fax:217-425-3220
Practice Address - Street 1:125 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IL
Practice Address - Zip Code:61727-1611
Practice Address - Country:US
Practice Address - Phone:217-935-9451
Practice Address - Fax:217-600-2442
Is Sole Proprietor?:No
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011763152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist