Provider Demographics
NPI:1124104690
Name:ELLSESSER, ANNA MARIA LOUISE (OD)
Entity type:Individual
Prefix:DR
First Name:ANNA
Middle Name:MARIA LOUISE
Last Name:ELLSESSER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:ANNA
Other - Middle Name:MARIA LOUISE
Other - Last Name:RUGGLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:30588 CENTER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145
Mailing Address - Country:US
Mailing Address - Phone:440-892-5367
Mailing Address - Fax:440-249-5094
Practice Address - Street 1:30588 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145
Practice Address - Country:US
Practice Address - Phone:440-892-5367
Practice Address - Fax:440-249-5094
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5569152W00000X
KY1657T152W00000X
OH5569/T2483152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3016711Medicaid
OHV06844Medicare UPIN
OH4304311Medicare PIN