Provider Demographics
NPI:1992739171
Name:MELCHERT, ELIZABETH CHRISTINE (OD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:CHRISTINE
Last Name:MELCHERT
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 1:21 PARK PL
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-8872
Mailing Address - Country:US
Mailing Address - Phone:920-739-4361
Mailing Address - Fax:
Practice Address - Street 1:21 PARK PL
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-8872
Practice Address - Country:US
Practice Address - Phone:920-739-4361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2094152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU45792Medicare UPIN
WI001745140Medicare PIN