MEDICARE: SUZETTE ANN BLAHNIK 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	OPC2506	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	OPC2506	OTHER	FL	OPTOMETRIST LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619927118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZETTE ANN BLAHNIK O.D.

Provider Business Mailing Address
First Line	:	3740 S RIDGEWOOD AVE UNIT 103
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-3519
Country	:	US
Telephone Number	:	386-492-6999
Fax Number	:	386-492-6900

Provider Business Practice Location Address
First Line	:	3740 S RIDGEWOOD AVE UNIT 103
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-3519
Country	:	US
Telephone Number	:	386-492-6999
Fax Number	:	386-492-6900

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

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	06/09/2009

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