MEDICARE: SUSAN C LODENQUAI 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	12700	CA

General Provider Information

NPI Number	:	1336146257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN C LODENQUAI O.D.

Provider Business Mailing Address
First Line	:	668B FREMONT AVE
Second Line	:
City	:	LOS ALTOS
State	:	CA
Zip	:	94024-4812
Country	:	US
Telephone Number	:	650-948-5061
Fax Number	:	650-948-5090

Provider Business Practice Location Address
First Line	:	668B FREMONT AVE
Second Line	:
City	:	LOS ALTOS
State	:	CA
Zip	:	94024-4812
Country	:	US
Telephone Number	:	650-948-5061
Fax Number	:	650-948-5090

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	11/04/2011

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