Provider Demographics
NPI:1649278953
Name:ELLENT, RITA (OD)
Entity type:Individual
Prefix:DR
First Name:RITA
Middle Name:
Last Name:ELLENT
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 1:12 STATION SQ
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5234
Mailing Address - Country:US
Mailing Address - Phone:917-803-0002
Mailing Address - Fax:
Practice Address - Street 1:8325 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7320
Practice Address - Country:US
Practice Address - Phone:718-426-2725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT005856152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY49890OtherDAVIS
NY02287781Medicaid
NY06286Medicare ID - Type Unspecified