Healthcare Provider Details

I. General information

NPI: 1104807809
Provider Name (Legal Business Name): JOSEPH J VANSUCH III O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 E KATELLA AVE SUITE 100
ORANGE CA
92867-4836
US

IV. Provider business mailing address

315 E KATELLA AVE
ORANGE CA
92867-4860
US

V. Phone/Fax

Practice location:
  • Phone: 714-997-3535
  • Fax: 714-771-4870
Mailing address:
  • Phone: 714-997-3535
  • Fax: 714-771-4870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number6373TPL
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6373TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: