Provider Demographics
NPI:1053397042
Name:EBBEN, ADRIAN PETER (OD)
Entity type:Individual
Prefix:DR
First Name:ADRIAN
Middle Name:PETER
Last Name:EBBEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:WI
Mailing Address - Zip Code:54136-1415
Mailing Address - Country:US
Mailing Address - Phone:920-788-5612
Mailing Address - Fax:920-788-0857
Practice Address - Street 1:222 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:WI
Practice Address - Zip Code:54136-1415
Practice Address - Country:US
Practice Address - Phone:920-788-5612
Practice Address - Fax:920-788-0857
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1330035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38568400Medicaid
WI38568400Medicaid