Provider Demographics
NPI:1376237412
Name:SMITH, SUSAN MARIE (LDO)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 WILDERNESS CIR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-4128
Mailing Address - Country:US
Mailing Address - Phone:904-714-8101
Mailing Address - Fax:
Practice Address - Street 1:1580 BRANAN FIELD RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8427
Practice Address - Country:US
Practice Address - Phone:904-214-9102
Practice Address - Fax:904-214-9054
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty