Provider Demographics
NPI:1174583587
Name:ELS, DORIS ANN (OD)
Entity type:Individual
Prefix:DR
First Name:DORIS
Middle Name:ANN
Last Name:ELS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DORIS
Other - Middle Name:ANN
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:121 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1509
Mailing Address - Country:US
Mailing Address - Phone:618-548-4866
Mailing Address - Fax:618-548-4867
Practice Address - Street 1:121 N BROADWAY
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1509
Practice Address - Country:US
Practice Address - Phone:618-548-4866
Practice Address - Fax:618-548-4867
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007117152W00000X
MOT02362152W00000X
IL346.000261152W00000X
ILMO0213619152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL215959OtherMEDICARE PTAN
ILP00084010OtherRAILROAD MEDICARE PTAN
ILIL7117OtherEYEMED
IL215959OtherMEDICARE PTAN
IL0152110001Medicare NSC
ILIL7117OtherEYEMED