Healthcare Provider Details

I. General information

NPI: 1114082112
Provider Name (Legal Business Name): DAVID J SUDER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10145 PACIFIC HEIGHTS BLVD STE 700
SAN DIEGO CA
92121-4234
US

IV. Provider business mailing address

10145 PACIFIC HEIGHTS BLVD STE 700
SAN DIEGO CA
92121-4234
US

V. Phone/Fax

Practice location:
  • Phone: 858-554-0799
  • Fax: 858-554-1306
Mailing address:
  • Phone: 858-554-0799
  • Fax: 858-554-1306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT7682T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: