Healthcare Provider Details

I. General information

NPI: 1790934982
Provider Name (Legal Business Name): SUSAN M. WHITEHEAD O.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2008
Last Update Date: 09/12/2008
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

400 W NORTHFIELD DR
BROWNSBURG IN
46112-8122
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002844
License Number StateIN

VIII. Authorized Official

Name: DR. SUSAN MAUREEN POE
Title or Position: PRESIDENT
Credential: O.D.
Phone: 317-459-0398