Healthcare Provider Details

I. General information

NPI: 1013916949
Provider Name (Legal Business Name): SUSAN ROST MONAHAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 PROFESSIONAL DR STE 300
PONTE VEDRA BEACH FL
32082-7232
US

IV. Provider business mailing address

150 PROFESSIONAL DR STE 300
PONTE VEDRA BEACH FL
32082-7232
US

V. Phone/Fax

Practice location:
  • Phone: 904-285-8448
  • Fax: 904-285-3410
Mailing address:
  • Phone: 904-285-8448
  • Fax: 904-285-3410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4106
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 4616
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: