Provider Demographics
NPI:1154686889
Name:LY, SUSAN (DR)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12527 CERROMAR PL
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6653
Mailing Address - Country:US
Mailing Address - Phone:703-338-8444
Mailing Address - Fax:703-817-0748
Practice Address - Street 1:14391 CHANTILLY CROSSING LN
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-2118
Practice Address - Country:US
Practice Address - Phone:703-817-0748
Practice Address - Fax:703-817-0748
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDTA2308152W00000X
VA0618002157152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist