Provider Demographics
NPI:1013528579
Name:AGOSTINELLI, ELISE DEBRULER (OD)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:DEBRULER
Last Name:AGOSTINELLI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:
Other - Last Name:DEBRULER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1720 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1720 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1816
Practice Address - Country:US
Practice Address - Phone:205-488-0736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-E53-TA-B84152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALS-E53-TA-B84Medicaid