Healthcare Provider Details

I. General information

NPI: 1942287511
Provider Name (Legal Business Name): ELISE L BEATTY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 VIRGINIA AVE
CONNERSVILLE IN
47331-2921
US

IV. Provider business mailing address

PO BOX 399
RICHMOND IN
47375-0399
US

V. Phone/Fax

Practice location:
  • Phone: 765-825-0660
  • Fax: 765-825-3075
Mailing address:
  • Phone: 765-962-2020
  • Fax: 765-966-2975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003182A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: