Provider Demographics
NPI:1194013086
Name:DEMETRULIAS, ANGELA JOANN (OD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:JOANN
Last Name:DEMETRULIAS
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:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5201 MID AMERICA PLZ
Practice Address - Street 2:DIV OPTHALMOLOGY, STE 2500
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-0002
Practice Address - Country:US
Practice Address - Phone:314-273-0020
Practice Address - Fax:314-273-0033
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016024156152W00000X
COOPT.0003857152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310034856Medicaid
ILENROLLEDMedicaid
IN716990001Medicare PIN
IN452570014Medicare PIN
IN160450001Medicare PIN
KYK026970Medicare PIN
INP01133201Medicare PIN