Provider Demographics
NPI:1003120460
Name:DR.SUSAN WESTRUP,LLC
Entity Type:Organization
Organization Name:DR.SUSAN WESTRUP,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTRUP
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:203-644-0804
Mailing Address - Street 1:26 LITTLE FOX LN
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-1403
Mailing Address - Country:US
Mailing Address - Phone:203-644-0804
Mailing Address - Fax:203-227-6212
Practice Address - Street 1:1201 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-2703
Practice Address - Country:US
Practice Address - Phone:203-644-0804
Practice Address - Fax:203-227-6212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-27
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002050152W00000X
NYTUV004169-1152W00000X
NJ27OA00423800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004142882Medicaid
CT004142882Medicaid
410000688Medicare PIN