Healthcare Provider Details

I. General information

NPI: 1447553482
Provider Name (Legal Business Name): SUSAN C DANBERG OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2010
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 NEW LONDON TPKE
GLASTONBURY CT
06033-4202
US

IV. Provider business mailing address

212 NEW LONDON TPKE
GLASTONBURY CT
06033-4202
US

V. Phone/Fax

Practice location:
  • Phone: 860-657-9189
  • Fax:
Mailing address:
  • Phone: 860-657-9189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1078
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number1078
License Number StateCT

VIII. Authorized Official

Name: DR. SUSAN C DANBERG
Title or Position: OWNER
Credential: OD
Phone: 860-657-9189