Provider Demographics
NPI:1457975484
Name:SMALL, ABBY ELIZABETH (OD)
Entity Type:Individual
Prefix:DR
First Name:ABBY
Middle Name:ELIZABETH
Last Name:SMALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ABBY
Other - Middle Name:ELIZABETH
Other - Last Name:BROERING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:911 W RACE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-1231
Mailing Address - Country:US
Mailing Address - Phone:260-251-8064
Mailing Address - Fax:
Practice Address - Street 1:1111 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1024
Practice Address - Country:US
Practice Address - Phone:260-726-4210
Practice Address - Fax:260-726-9347
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004215A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist