MEDICARE: DR. SUSAN MARIE GOODE 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	18003062A	IN

General Provider Information

NPI Number	:	1659427102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN MARIE GOODE O.D.

Provider Business Mailing Address
First Line	:	14413 ILLINOIS RD
Second Line	:	STE. C
City	:	FORT WAYNE
State	:	IN
Zip	:	46814-9714
Country	:	US
Telephone Number	:	260-616-0184
Fax Number	:	855-271-9517

Provider Business Practice Location Address
First Line	:	14413 ILLINOIS RD
Second Line	:	STE. C
City	:	FORT WAYNE
State	:	IN
Zip	:	46814-9714
Country	:	US
Telephone Number	:	260-616-0184
Fax Number	:	855-271-9517

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

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	07/27/2012

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