Provider Demographics
NPI:1285635581
Name:WISE, SUSAN BEARD (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:BEARD
Last Name:WISE
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 1:63 CHESTNUT ST
Mailing Address - Street 2:P. O. BOX 850
Mailing Address - City:MARS HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28754-7542
Mailing Address - Country:US
Mailing Address - Phone:828-689-4206
Mailing Address - Fax:828-689-5007
Practice Address - Street 1:63 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MARS HILL
Practice Address - State:NC
Practice Address - Zip Code:28754-7542
Practice Address - Country:US
Practice Address - Phone:828-689-4206
Practice Address - Fax:828-689-4206
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1472152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0261NOtherBCBS GROUP NUMBER
NC89093NJMedicaid
NC2468226DMedicare ID - Type UnspecifiedINDIVIDUAL NUMBER
NC89093NJMedicaid