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General NPI Number Information
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NPI Number | 1194013086
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Entity Type | Individual
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Provider Name | ANGELA JOANN DEMETRULIAS OD
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Gender | Female
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Dates
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Enumeration Date | 07/13/2011
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Last Update Date | 01/12/2023
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Provider Practice Location Address
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Address Line | 5201 MID AMERICA PLZ DIV OPTHALMOLOGY, STE 2500
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City | SAINT LOUIS
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State | MO
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Zip | 63129-0002
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Country | US
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Telephone | 314-273-0020
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Fax | 314-273-0033
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Provider Business Mailing Address
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Address Line | PO BOX 110429
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City | AURORA
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State | CO
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Zip | 80042-0429
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2016024156
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPT.0003857
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License Number State | CO
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