MEDICARE: DR. SUSAN TRUONG CERVANTES 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	OPT 12923	CA

General Provider Information

NPI Number	:	1164423240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN TRUONG CERVANTES O.D.

Provider Business Mailing Address
First Line	:	1662 MAIN ST STE B
Second Line	:
City	:	RAMONA
State	:	CA
Zip	:	92065-5231
Country	:	US
Telephone Number	:	760-788-3622
Fax Number	:	760-788-4781

Provider Business Practice Location Address
First Line	:	1662 MAIN ST STE B
Second Line	:
City	:	RAMONA
State	:	CA
Zip	:	92065-5231
Country	:	US
Telephone Number	:	760-788-3622
Fax Number	:	760-788-4781

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

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	09/05/2008

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