Healthcare Provider Details

I. General information

NPI: 1548187909
Provider Name (Legal Business Name): SUSANNA S. TAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9221 SIERRA COLLEGE BLVD STE 130
ROSEVILLE CA
95661-5934
US

IV. Provider business mailing address

9221 SIERRA COLLEGE BLVD STE 130
ROSEVILLE CA
95661-5934
US

V. Phone/Fax

Practice location:
  • Phone: 916-797-6747
  • Fax: 916-797-6747
Mailing address:
  • Phone: 916-797-6747
  • Fax: 916-797-6747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number36343
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: