Provider Demographics
NPI:1598115289
Name:CONGDON, ELIZABETH MARIE (OD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:CONGDON
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 1:1035 KEPLER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8320
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:
Practice Address - Street 1:2253 W MASON ST
Practice Address - Street 2:#100
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4706
Practice Address - Country:US
Practice Address - Phone:920-327-7000
Practice Address - Fax:920-327-7005
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3418152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist