Provider Demographics
NPI:1851360648
Name:KOLLBAUM, ELLI J (OD)
Entity Type:Individual
Prefix:DR
First Name:ELLI
Middle Name:J
Last Name:KOLLBAUM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:ELLI
Other - Middle Name:J
Other - Last Name:REICHELT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:800 E ATWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-3635
Mailing Address - Country:US
Mailing Address - Phone:812-855-4447
Mailing Address - Fax:
Practice Address - Street 1:800 E ATWATER AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3635
Practice Address - Country:US
Practice Address - Phone:812-855-4447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002935152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200284870Medicaid
IN200284870Medicaid
IN544150YYMedicare PIN
IN546000YMedicare PIN
IN825700VVMedicare PIN