Healthcare Provider Details

I. General information

NPI: 1508412065
Provider Name (Legal Business Name): SUSAN SUNNY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 SOUTH BLVD E
ROCHESTER HILLS MI
48307-6122
US

IV. Provider business mailing address

33080 UTICA RD
FRASER MI
48026-2038
US

V. Phone/Fax

Practice location:
  • Phone: 248-293-5161
  • Fax: 248-564-2954
Mailing address:
  • Phone: 586-296-7250
  • Fax: 586-296-7256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005407
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: