Provider Demographics
NPI:1396059002
Name:ELLER, MICHAEL C (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:ELLER
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 1:310 THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4569
Mailing Address - Country:US
Mailing Address - Phone:870-862-4216
Mailing Address - Fax:870-862-9011
Practice Address - Street 1:310 THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4569
Practice Address - Country:US
Practice Address - Phone:870-862-4216
Practice Address - Fax:870-862-9011
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00986548OtherRAILROAD MEDICARE
AR188676722Medicaid
AR0C263Medicare PIN