MEDICARE: MRS. SUZANNE R MAYSTEAD 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	4901SM002704	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200000002364	OTHER		PHP
2	SM002704	OTHER		BLUE CROSS

General Provider Information

NPI Number	:	1932187911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUZANNE R MAYSTEAD OD

Provider Business Mailing Address
First Line	:	1311 E BRIDGE STREET
Second Line	:
City	:	PORTLAND
State	:	MI
Zip	:	48875
Country	:	US
Telephone Number	:	517-647-7515
Fax Number	:	517-647-5445

Provider Business Practice Location Address
First Line	:	1311 E BRIDGE STREET
Second Line	:
City	:	PORTLAND
State	:	MI
Zip	:	48875
Country	:	US
Telephone Number	:	517-647-7515
Fax Number	:	517-647-5445

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

Provider Enumeration Date	:	01/09/2006
Last Update Date	:	04/07/2011

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