Provider Demographics
NPI:1972595460
Name:DEAN, ELMO CLYDE JR (OD)
Entity type:Individual
Prefix:DR
First Name:ELMO
Middle Name:CLYDE
Last Name:DEAN
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4747 ONEAL LN
Mailing Address - Street 2:STE. A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-1638
Mailing Address - Country:US
Mailing Address - Phone:225-755-0988
Mailing Address - Fax:225-755-3235
Practice Address - Street 1:4747 ONEAL LN
Practice Address - Street 2:STE. A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-1638
Practice Address - Country:US
Practice Address - Phone:225-755-0988
Practice Address - Fax:225-755-3235
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA843-071T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1317918Medicaid
LA47513Medicare PIN
LA1317918Medicaid