Provider Demographics
NPI:1295834299
Name:SUTER, PENELOPE SHOLES (OD)
Entity Type:Individual
Prefix:DR
First Name:PENELOPE
Middle Name:SHOLES
Last Name:SUTER
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 1:5300 CALIFORNIA AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-1642
Mailing Address - Country:US
Mailing Address - Phone:661-869-2010
Mailing Address - Fax:661-869-2708
Practice Address - Street 1:5300 CALIFORNIA AVE STE 210
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-1642
Practice Address - Country:US
Practice Address - Phone:661-869-2010
Practice Address - Fax:661-869-2708
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA08128T152WV0400X, 225400000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD001690Medicaid
CASD0081280Medicaid
CASD0081280Medicaid
CASD0081280Medicare PIN