Provider Demographics
NPI:1558314120
Name:LIKENS, ELWOOD GLENN (OD)
Entity Type:Individual
Prefix:DR
First Name:ELWOOD
Middle Name:GLENN
Last Name:LIKENS
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 1:332 BATCHELOR BAY RD
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-7110
Mailing Address - Country:US
Mailing Address - Phone:910-552-0093
Mailing Address - Fax:910-937-1296
Practice Address - Street 1:2025 N MARINE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6920
Practice Address - Country:US
Practice Address - Phone:910-937-1297
Practice Address - Fax:910-937-1296
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1550152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890903RMedicaid
NC890903RMedicaid
NC2323503Medicare ID - Type Unspecified