Provider Demographics
NPI:1194393645
Name:SUSOL, ALEKSANDRA (OD)
Entity Type:Individual
Prefix:
First Name:ALEKSANDRA
Middle Name:
Last Name:SUSOL
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 1:942 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2601
Mailing Address - Country:US
Mailing Address - Phone:312-829-6800
Mailing Address - Fax:
Practice Address - Street 1:942 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2601
Practice Address - Country:US
Practice Address - Phone:312-829-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011508152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist