Provider Demographics
NPI:1316376825
Name:TOLEDO, SUSANA (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSANA
Middle Name:
Last Name:TOLEDO
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 1:5718 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-5508
Mailing Address - Country:US
Mailing Address - Phone:773-498-2985
Mailing Address - Fax:773-498-6042
Practice Address - Street 1:5718 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-5508
Practice Address - Country:US
Practice Address - Phone:773-498-2985
Practice Address - Fax:773-498-6042
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010752152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist