MEDICARE: DR. PATRICE C ELLINGSON O.D.

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	18002448	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	410017027	OTHER	IN	MEDICARE RR
5	410040819	OTHER	IN	MEDICARE RR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000243494	OTHER	IN	ANTHEM NONPAR
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639163884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PATRICE C ELLINGSON O.D.

Provider Business Mailing Address
First Line	:	1515 E PAULDING RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-1252
Country	:	US
Telephone Number	:	260-744-2273
Fax Number	:	260-744-4555

Provider Business Practice Location Address
First Line	:	1515 E PAULDING RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816
Country	:	US
Telephone Number	:	260-744-2273
Fax Number	:	260-744-4555

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

Provider Enumeration Date	:	09/02/2005
Last Update Date	:	08/15/2018

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Directions to “ DR. PATRICE C ELLINGSON O.D.” Practice Location

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