Provider Demographics
NPI:1639163884
Name:ELLINGSON, PATRICE C (OD)
Entity Type:Individual
Prefix:DR
First Name:PATRICE
Middle Name:C
Last Name:ELLINGSON
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 1:1515 E PAULDING RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46816-1252
Mailing Address - Country:US
Mailing Address - Phone:260-744-2273
Mailing Address - Fax:260-744-4555
Practice Address - Street 1:1515 E PAULDING RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816
Practice Address - Country:US
Practice Address - Phone:260-744-2273
Practice Address - Fax:260-744-4555
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002448152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000243494OtherANTHEM NONPAR
IN100411890Medicaid
IN100411890AMedicaid
IN410017027OtherMEDICARE RR
IN410040819OtherMEDICARE RR
IN410040819OtherMEDICARE RR
IN100411890Medicaid
IN669220017Medicare PIN
INU16518Medicare UPIN
IN0258750005Medicare NSC
IN000000243494OtherANTHEM NONPAR