Basic Information
| Provider Information | |||||||||
| NPI: | 1528440740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LORD | ||||||||
| FirstName: | ELISE | ||||||||
| MiddleName: | AUBREY | ||||||||
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| Credential: | O.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 E ATWATER AVE | ||||||||
| Address2: | RM 264 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474053635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128553670 | ||||||||
| FaxNumber: | 8128556116 | ||||||||
| Practice Location | |||||||||
| Address1: | 744 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474053603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128558436 | ||||||||
| FaxNumber: | 8128551683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2015 | ||||||||
| LastUpdateDate: | 10/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18003905A | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 201298910 | 05 | IN | MEDICAID |