Provider Demographics
NPI:1366693178
Name:DAVID H SUSEWITZ
Entity Type:Organization
Organization Name:DAVID H SUSEWITZ
Other - Org Name:OPTICAL IDEAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SUSEWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-675-4060
Mailing Address - Street 1:2644 W JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2803
Mailing Address - Country:US
Mailing Address - Phone:734-675-4060
Mailing Address - Fax:
Practice Address - Street 1:2644 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2803
Practice Address - Country:US
Practice Address - Phone:734-675-4060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900H21185OtherBLUE CROSS
MI6126220001Medicare NSC