Provider Demographics
NPI:1902835671
Name:AGOSTINELLI, KIMBERLY A (OD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:A
Last Name:AGOSTINELLI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:SUCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:921 DRINKER TPKE STE 15
Mailing Address - Street 2:
Mailing Address - City:COVINGTON TWP
Mailing Address - State:PA
Mailing Address - Zip Code:18444-7948
Mailing Address - Country:US
Mailing Address - Phone:570-842-0331
Mailing Address - Fax:
Practice Address - Street 1:921 DRINKER TPKE STE 15
Practice Address - Street 2:
Practice Address - City:COVINGTON TWP
Practice Address - State:PA
Practice Address - Zip Code:18444-7948
Practice Address - Country:US
Practice Address - Phone:570-842-0331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000799152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1902835671OtherNPI INDIVIDUAL
PA1104834266OtherNPI
PA5879980001Medicare NSC
PA1104834266OtherNPI
PA044425Medicare ID - Type Unspecified