Provider Demographics
NPI:1467590679
Name:DEVINE, SUSAN J (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:J
Last Name:DEVINE
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 1:31 WATCHAUG RD
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:CT
Mailing Address - Zip Code:06071-1118
Mailing Address - Country:US
Mailing Address - Phone:860-763-4792
Mailing Address - Fax:
Practice Address - Street 1:44 PROSPECT HILL RD
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06088-9501
Practice Address - Country:US
Practice Address - Phone:860-623-8013
Practice Address - Fax:860-627-6433
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2404152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004157493Medicaid
CTU60725Medicare UPIN
CT004157493Medicaid