Provider Demographics
NPI:1124179361
Name:BROWN, SUSAN (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BROWN
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 1:23412 PACIFIC PARK DR
Mailing Address - Street 2:#30F
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3321
Mailing Address - Country:US
Mailing Address - Phone:714-318-4242
Mailing Address - Fax:
Practice Address - Street 1:190 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3602
Practice Address - Country:US
Practice Address - Phone:714-669-1121
Practice Address - Fax:714-669-9786
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12646152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV01476Medicare UPIN
CAWOP12646Medicare ID - Type Unspecified