Provider Demographics
NPI:1740214188
Name:ELLINGTON, JERRY N (OD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:N
Last Name:ELLINGTON
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 1:560 DABNEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536
Mailing Address - Country:US
Mailing Address - Phone:252-438-6132
Mailing Address - Fax:252-438-5161
Practice Address - Street 1:560 DABNEY DRIVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536
Practice Address - Country:US
Practice Address - Phone:252-438-6132
Practice Address - Fax:252-438-5161
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1455152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909180Medicaid
NC890920FMedicaid
2468244Medicare ID - Type Unspecified
2468244AMedicare ID - Type Unspecified
U37328Medicare UPIN
NC890920FMedicaid