Provider Demographics
NPI:1447242144
Name:ROBERTS-SUCHON, SHARON R (OD)
Entity Type:Individual
Prefix:DR
First Name:SHARON
Middle Name:R
Last Name:ROBERTS-SUCHON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:SHARON
Other - Middle Name:R
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:100 CARR ROAD
Mailing Address - Street 2:PO BOX 600
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-0600
Mailing Address - Country:US
Mailing Address - Phone:920-893-3937
Mailing Address - Fax:920-892-6668
Practice Address - Street 1:100 CARR ROAD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-0600
Practice Address - Country:US
Practice Address - Phone:920-893-3937
Practice Address - Fax:920-892-6668
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI2028152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38526500Medicaid
WIT63118Medicare UPIN
WI38526500Medicaid