Provider Demographics
NPI:1265603385
Name:ELLISON, MARY E (OPTICIAN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:ELLISON
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MEDICAL PARK
Mailing Address - Street 2:TOWER 3, SUITE 223
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-6391
Mailing Address - Country:US
Mailing Address - Phone:304-243-7879
Mailing Address - Fax:304-243-3901
Practice Address - Street 1:30 MEDICAL PARK
Practice Address - Street 2:TOWER 3, SUITE 223
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6391
Practice Address - Country:US
Practice Address - Phone:304-243-7879
Practice Address - Fax:304-243-3901
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVNON LICENSED STATE156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician