Provider Demographics
NPI:1659335479
Name:FEITZ, ELLYN ELAINE (OD)
Entity Type:Individual
Prefix:DR
First Name:ELLYN
Middle Name:ELAINE
Last Name:FEITZ
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 1:417 E COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356-1814
Mailing Address - Country:US
Mailing Address - Phone:219-696-3000
Mailing Address - Fax:219-696-2205
Practice Address - Street 1:417 E COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:IN
Practice Address - Zip Code:46356-1814
Practice Address - Country:US
Practice Address - Phone:219-696-3000
Practice Address - Fax:219-696-2205
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002169B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T34990Medicare UPIN
IN0451830001Medicare NSC
FE708350BMedicare ID - Type Unspecified