Healthcare Provider Details

I. General information

NPI: 1104922079
Provider Name (Legal Business Name): SUSAN MAUREEN POE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W NORTHFIELD DR
BROWNSBURG IN
46112-8122
US

IV. Provider business mailing address

5790 GYRFALCON PL
CARMEL IN
46033-8938
US

V. Phone/Fax

Practice location:
  • Phone: 317-858-3083
  • Fax: 317-858-8403
Mailing address:
  • Phone: 317-818-0609
  • Fax: 317-858-8403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002844B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: