Healthcare Provider Details

I. General information

NPI: 1457975484
Provider Name (Legal Business Name): ABBY ELIZABETH SMALL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ABBY ELIZABETH BROERING

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N MERIDIAN ST
PORTLAND IN
47371-1024
US

IV. Provider business mailing address

911 W RACE ST
PORTLAND IN
47371-1231
US

V. Phone/Fax

Practice location:
  • Phone: 260-726-4210
  • Fax: 260-726-9347
Mailing address:
  • Phone: 260-251-8064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18004215A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: