=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497752356
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN H PAYNE O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2005
-----------------------------------------------------
Last Update Date | 07/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4051 UPPER CREEK DR STE 107
-----------------------------------------------------
City | SUN CITY CENTER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33573-6825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-634-8877
-----------------------------------------------------
Fax | 813-634-2266
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 VONDERBURG DR STE 101
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-5982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-681-1122
-----------------------------------------------------
Fax | 813-684-4924
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC3517
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------