Provider Demographics
NPI:1073211124
Name:HICKERSON, SUZANNE (LDO)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:SUZIE
Other - Middle Name:
Other - Last Name:HICKERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1801 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2303
Mailing Address - Country:US
Mailing Address - Phone:937-339-3694
Mailing Address - Fax:
Practice Address - Street 1:1801 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2303
Practice Address - Country:US
Practice Address - Phone:937-339-3694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.15483S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician