Provider Demographics
NPI:1417008350
Name:SUSEWITZ, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SUSEWITZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900H21185OtherBLUE CROSS
MI900H21185OtherBLUE CROSS