MEDICARE: DR. SUSAN MARIE GLAD O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2319ATI	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	059337000	OTHER	OR	REGENCE BLUE CROSS BLUE S

General Provider Information

NPI Number	:	1073694253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN MARIE GLAD O.D.

Provider Business Mailing Address
First Line	:	140 SW POPLAR ST
Second Line	:
City	:	YAMHILL
State	:	OR
Zip	:	97148-8046
Country	:	US
Telephone Number	:	503-434-1140
Fax Number	:

Provider Business Practice Location Address
First Line	:	2375 NORTH HIGHWAY 99W
Second Line	:
City	:	MCMINNVILLE
State	:	OR
Zip	:	97128
Country	:	US
Telephone Number	:	503-434-1140
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	09/21/2010

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