Provider Demographics
NPI:1588894695
Name:SHORTER, ELLEN S (OD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:S
Last Name:SHORTER
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 1:1855 W TAYLOR ST
Mailing Address - Street 2:CONTACT LENS SERVICE
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-7242
Mailing Address - Country:US
Mailing Address - Phone:312-996-5410
Mailing Address - Fax:
Practice Address - Street 1:1855 W TAYLOR ST
Practice Address - Street 2:CONTACT LENS SERVICE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7242
Practice Address - Country:US
Practice Address - Phone:312-996-5410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-010248152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist