Healthcare Provider Details

I. General information

NPI: 1174583587
Provider Name (Legal Business Name): DORIS ANN ELS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DORIS ANN OSBORNE OD

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N BROADWAY
SALEM IL
62881-1509
US

IV. Provider business mailing address

121 N BROADWAY
SALEM IL
62881-1509
US

V. Phone/Fax

Practice location:
  • Phone: 618-548-4866
  • Fax: 618-548-4867
Mailing address:
  • Phone: 618-548-4866
  • Fax: 618-548-4867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007117
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02362
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number346.000261
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMO0213619
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: