Provider Demographics
NPI:1558468447
Name:LOVETT, ELLYN M (OD)
Entity Type:Individual
Prefix:DR
First Name:ELLYN
Middle Name:M
Last Name:LOVETT
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 1:752 WOOD STREAM XING
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-2972
Mailing Address - Country:US
Mailing Address - Phone:219-476-0343
Mailing Address - Fax:
Practice Address - Street 1:6087 US HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5046
Practice Address - Country:US
Practice Address - Phone:219-759-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002888152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU66892Medicare UPIN
IN091380BMedicare ID - Type Unspecified