Provider Demographics
NPI:1629459581
Name:ELLISON, ELIZABETH F (OD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:F
Last Name:ELLISON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:M
Other - Last Name:FIORAVANTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2061 BEVERLY RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2034
Mailing Address - Country:US
Mailing Address - Phone:770-532-4444
Mailing Address - Fax:678-971-5172
Practice Address - Street 1:2061 BEVERLY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2034
Practice Address - Country:US
Practice Address - Phone:770-532-4444
Practice Address - Fax:678-971-5172
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002868152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003169594AMedicaid
GA003169594AMedicaid