Provider Demographics
NPI:1164485405
Name:STEWART, SUSAN B (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:STEWART
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:BEALL
Other - Last Name:LUKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1550 S POTOMAC ST
Mailing Address - Street 2:SUITE 155
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012
Mailing Address - Country:US
Mailing Address - Phone:303-369-1020
Mailing Address - Fax:
Practice Address - Street 1:1550 S POTOMAC ST
Practice Address - Street 2:SUITE 155
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012
Practice Address - Country:US
Practice Address - Phone:303-369-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS798TA211152W00000X
CA14677TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009976235Medicaid
AL009976245Medicaid
AL051526309OtherBLUE CROSS OF ALABAMA
AL051000468OtherBLUE CROSS OF ALABAMA
ALP00160737OtherRAILROAD MEDICARE
ALP00160737OtherRAILROAD MEDICARE
AL051000468OtherBLUE CROSS OF ALABAMA