Provider Demographics
NPI:1710972450
Name:ELLENBECKER, WAYNE D (OD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:D
Last Name:ELLENBECKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 W RIVERSTONE DR
Mailing Address - Street 2:STE 101
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4968
Mailing Address - Country:US
Mailing Address - Phone:208-667-2255
Mailing Address - Fax:208-765-5889
Practice Address - Street 1:1250 W IRONWOOD DR
Practice Address - Street 2:SUITE 201
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2679
Practice Address - Country:US
Practice Address - Phone:208-667-2255
Practice Address - Fax:208-765-5889
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002689900Medicaid
ID002689900Medicaid
T66868Medicare UPIN