Healthcare Provider Details

I. General information

NPI: 1831170463
Provider Name (Legal Business Name): SUSAN ANN OH OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 CHERRY ST
SAN CARLOS CA
94070-3110
US

IV. Provider business mailing address

2575 YORBA LINDA BLVD
FULLERTON CA
92831-1615
US

V. Phone/Fax

Practice location:
  • Phone: 650-593-1661
  • Fax: 650-595-5203
Mailing address:
  • Phone: 714-449-7430
  • Fax: 714-992-7850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11935T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: