MEDICARE: DR. ELLYN ELAINE FEITZ OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	18002169B	IN

General Provider Information

NPI Number	:	1659335479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLYN ELAINE FEITZ OD

Provider Business Mailing Address
First Line	:	417 E COMMERCIAL AVE
Second Line	:
City	:	LOWELL
State	:	IN
Zip	:	46356-1814
Country	:	US
Telephone Number	:	219-696-3000
Fax Number	:	219-696-2205

Provider Business Practice Location Address
First Line	:	417 E COMMERCIAL AVE
Second Line	:
City	:	LOWELL
State	:	IN
Zip	:	46356-1814
Country	:	US
Telephone Number	:	219-696-3000
Fax Number	:	219-696-2205

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	05/21/2009

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