Provider Demographics
NPI:1992996383
Name:PETROCZKY, ELLEN RENEE (OD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:RENEE
Last Name:PETROCZKY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:178 LONGFORD DR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-4688
Mailing Address - Country:US
Mailing Address - Phone:815-291-7647
Mailing Address - Fax:
Practice Address - Street 1:363 S RANDALL RD
Practice Address - Street 2:ELGIN FAMILY EYE CARE
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-5526
Practice Address - Country:US
Practice Address - Phone:847-888-1555
Practice Address - Fax:847-888-2508
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.009976152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist