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NPI Code Detail

MEDICARE: SUSAN GRESHAM OD

MEDICARE: SUSAN GRESHAM OD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometrist0618002780VA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1053975763
Entity Type Code : Individual
Provider Name (Legal Business Name) : SUSAN GRESHAM OD
Provider Business Mailing Address
First Line : 17 N MEDICAL PARK DR
Second Line :
City : FISHERSVILLE
State : VA
Zip : 22939-2344
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1500 COMMERCE RD
Second Line :
City : STAUNTON
State : VA
Zip : 24401-9032
Country : US
Telephone Number : 540-213-7720
Fax Number : 540-213-9441
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/28/2019
Last Update Date : 07/07/2020

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