Provider Demographics
NPI:1184665259
Name:SUSSEX, MICHAEL L (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:SUSSEX
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036
Mailing Address - Country:US
Mailing Address - Phone:517-278-6303
Mailing Address - Fax:517-279-8000
Practice Address - Street 1:350 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036
Practice Address - Country:US
Practice Address - Phone:517-278-6303
Practice Address - Fax:517-279-8000
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002713152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS002713OtherBCBS
OM60150Medicare PIN
U11904Medicare UPIN
M60130003Medicare PIN
OM60130Medicare PIN
M60150002Medicare PIN