MEDICARE: DR. SUZANNE MARIE JOHANNES OD

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	OPT003195	GA

General Provider Information

NPI Number	:	1245885201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUZANNE MARIE JOHANNES OD

Provider Business Mailing Address
First Line	:	2505 LOVE LN
Second Line	:
City	:	SODDY DAISY
State	:	TN
Zip	:	37379-3040
Country	:	US
Telephone Number	:	423-664-2356
Fax Number	:

Provider Business Practice Location Address
First Line	:	1341 W WALNUT AVE
Second Line	:
City	:	DALTON
State	:	GA
Zip	:	30720-3857
Country	:	US
Telephone Number	:	706-275-9900
Fax Number	:

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

Provider Enumeration Date	:	08/07/2019
Last Update Date	:	08/07/2019

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