Provider Demographics
NPI:1447765748
Name:SUDDUTH VISION PLLC
Entity Type:Organization
Organization Name:SUDDUTH VISION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:SUDDUTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:206-419-5166
Mailing Address - Street 1:4538 POLARIS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-5025
Mailing Address - Country:US
Mailing Address - Phone:206-419-5166
Mailing Address - Fax:
Practice Address - Street 1:8000 PARRAMORE RD.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244
Practice Address - Country:US
Practice Address - Phone:206-419-5166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4882152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1316370414OtherNPI