Provider Demographics
NPI:1598712002
Name:BEREKETAB, ELILTA (OD)
Entity Type:Individual
Prefix:
First Name:ELILTA
Middle Name:
Last Name:BEREKETAB
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:PO BOX 757
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-0757
Mailing Address - Country:US
Mailing Address - Phone:309-829-5311
Mailing Address - Fax:
Practice Address - Street 1:123 N 8TH ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1443
Practice Address - Country:US
Practice Address - Phone:309-829-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009523152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
K06764Medicare PIN
U87796Medicare UPIN