Provider Demographics
NPI:1497752356
Name:PAYNE, SUSAN H (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:PAYNE
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 1:403 VONDERBURG DR
Mailing Address - Street 2:STE 101
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5982
Mailing Address - Country:US
Mailing Address - Phone:813-681-1122
Mailing Address - Fax:813-684-4924
Practice Address - Street 1:4051 UPPER CREEK DR
Practice Address - Street 2:STE 107
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-6825
Practice Address - Country:US
Practice Address - Phone:813-634-8877
Practice Address - Fax:813-634-2266
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3517152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20976OtherBCBS FLORIDA
FL2508546OtherAENTA
FL7286206OtherAETNA
FL620559300Medicaid
NY6599633OtherGHI
FLE4875ZMedicare ID - Type Unspecified
FL7286206OtherAETNA
FL620559300Medicaid
FL2508546OtherAENTA
GA410044413Medicare PIN
FLE4875WMedicare PIN