Provider Demographics
NPI:1417282195
Name:NIXON, SUSAN DALE (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DALE
Last Name:NIXON
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 1:5225 ELMORE AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3454
Mailing Address - Country:US
Mailing Address - Phone:563-355-5731
Mailing Address - Fax:563-355-5481
Practice Address - Street 1:5225 ELMORE AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3454
Practice Address - Country:US
Practice Address - Phone:563-355-5731
Practice Address - Fax:563-355-5481
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-13
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009024362152W00000X
KS1845152W00000X
IA002567152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist