Provider Demographics
NPI:1073694253
Name:GLAD, SUSAN MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:GLAD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 SW POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:YAMHILL
Mailing Address - State:OR
Mailing Address - Zip Code:97148-8046
Mailing Address - Country:US
Mailing Address - Phone:503-434-1140
Mailing Address - Fax:
Practice Address - Street 1:2375 NORTH HIGHWAY 99W
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128
Practice Address - Country:US
Practice Address - Phone:503-434-1140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2319ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR059337000OtherREGENCE BLUE CROSS BLUE S