Provider Demographics
NPI:1427033034
Name:GORZ, SUSAN ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ANN
Last Name:GORZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:ANN
Other - Last Name:ZUMWALT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1021 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ALGOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54201-1737
Mailing Address - Country:US
Mailing Address - Phone:920-487-2077
Mailing Address - Fax:920-487-9770
Practice Address - Street 1:1217 ELLIS ST
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216-1825
Practice Address - Country:US
Practice Address - Phone:920-388-2020
Practice Address - Fax:920-388-3594
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2044152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000147383OtherMEDICARE PTAN
WI87727OtherMEDICARE
WI38526300Medicaid
WI037174001OtherMEDICARE NSC
WI87544OtherMEDICARE
WI38709200Medicaid
WI000147383OtherMEDICARE PTAN
T62036Medicare UPIN
WI87544OtherMEDICARE