Provider Demographics
NPI:1942287511
Name:BEATTY, ELISE L (OD)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:L
Last Name:BEATTY
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:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47375-0399
Mailing Address - Country:US
Mailing Address - Phone:765-962-2020
Mailing Address - Fax:765-966-2975
Practice Address - Street 1:2045 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2921
Practice Address - Country:US
Practice Address - Phone:765-825-0660
Practice Address - Fax:765-825-3075
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003182A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200395910Medicaid
OH2354241Medicaid
U91810Medicare UPIN
OHP00765029Medicare PIN
IN263670AMedicare PIN
IN200395910Medicaid