Provider Demographics
NPI:1184686883
Name:QUADE, SUSAN MITHOFF (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MITHOFF
Last Name:QUADE
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 1:2299 WEST RD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-3615
Mailing Address - Country:US
Mailing Address - Phone:734-676-4500
Mailing Address - Fax:734-676-1587
Practice Address - Street 1:2299 WEST RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-3615
Practice Address - Country:US
Practice Address - Phone:734-676-4500
Practice Address - Fax:734-676-1587
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003686152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900130980OtherTAX ID
MI900H22910OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI900130980OtherTAX ID
MI900H22910OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI0N86570Medicare ID - Type Unspecified