Provider Demographics
NPI:1407936925
Name:ELI DRAGISICH OD INC
Entity Type:Organization
Organization Name:ELI DRAGISICH OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELI
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAGISICH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-723-1280
Mailing Address - Street 1:705 COLLIERS WAY
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5016
Mailing Address - Country:US
Mailing Address - Phone:304-723-1280
Mailing Address - Fax:
Practice Address - Street 1:705 COLLIERS WAY
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5016
Practice Address - Country:US
Practice Address - Phone:304-723-1280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV599OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150189000Medicaid
WV0150189000Medicaid
WVT32543Medicare UPIN