Provider Demographics
NPI:1245301787
Name:ELLENDER, MICHAEL SCOTT (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:ELLENDER
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 1:1601 MOUNT RUSHMORE RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-4588
Mailing Address - Country:US
Mailing Address - Phone:605-348-7401
Mailing Address - Fax:605-348-9773
Practice Address - Street 1:1601 MOUNT RUSHMORE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4588
Practice Address - Country:US
Practice Address - Phone:605-348-7401
Practice Address - Fax:605-348-9773
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDT573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9201210Medicaid
SD9201210Medicaid
SDU56565Medicare UPIN
SDS40068Medicare PIN