Provider Demographics
NPI:1437715091
Name:AVERY, ELIZABETH GRACE (OD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:GRACE
Last Name:AVERY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1200 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1759
Mailing Address - Country:US
Mailing Address - Phone:734-654-2169
Mailing Address - Fax:517-263-1866
Practice Address - Street 1:1200 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1759
Practice Address - Country:US
Practice Address - Phone:517-280-1830
Practice Address - Fax:517-264-6575
Is Sole Proprietor?:No
Enumeration Date:2019-05-19
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005728152W00000X
OHOPT.006782152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist