Provider Demographics
NPI:1639458276
Name:DISTEFANO, ELIZABETH NOEL (OD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:NOEL
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:NOEL
Other - Last Name:RANDOLPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2585 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1642
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:42 MCGINNIS DR
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:WV
Practice Address - Zip Code:25570-9553
Practice Address - Country:US
Practice Address - Phone:304-272-5136
Practice Address - Fax:304-272-6261
Is Sole Proprietor?:No
Enumeration Date:2011-08-14
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002273152W00000X
WV2045-IOD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist