Provider Demographics
NPI:1053401935
Name:DOHR, ELLEN MARY (OD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARY
Last Name:DOHR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 SHELDRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864
Mailing Address - Country:US
Mailing Address - Phone:517-349-9423
Mailing Address - Fax:
Practice Address - Street 1:2333 JOLLY RD
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864
Practice Address - Country:US
Practice Address - Phone:517-381-2000
Practice Address - Fax:517-381-2006
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U11064Medicare UPIN