Provider Demographics
NPI:1548328438
Name:MILLIE, ELISE A (OD)
Entity type:Individual
Prefix:MS
First Name:ELISE
Middle Name:A
Last Name:MILLIE
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 1:502 S FREMONT AVE
Mailing Address - Street 2:APT #123
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2068
Mailing Address - Country:US
Mailing Address - Phone:702-308-3569
Mailing Address - Fax:
Practice Address - Street 1:502 S FREMONT AVE
Practice Address - Street 2:APT #123
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2068
Practice Address - Country:US
Practice Address - Phone:702-308-3569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV544152W00000X
TNOD 2576152W00000X
FLOPC 3924152W00000X
KY1625DT152W00000X
CAOPT13430T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist