Provider Demographics
NPI:1811285869
Name:HARVEY, ELISSA SUE (OD)
Entity type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:SUE
Last Name:HARVEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:ELISSA
Other - Middle Name:SUE
Other - Last Name:HEFLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:400 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1514
Mailing Address - Country:US
Mailing Address - Phone:618-548-3506
Mailing Address - Fax:618-548-2555
Practice Address - Street 1:400 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1514
Practice Address - Country:US
Practice Address - Phone:618-548-3506
Practice Address - Fax:618-548-2555
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-010446152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILME2433554OtherDEA