Provider Demographics
NPI:1497912174
Name:MOON, SUSAN MARIE (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:MOON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:WARD-MOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 231
Mailing Address - Street 2:
Mailing Address - City:EAST TAWAS
Mailing Address - State:MI
Mailing Address - Zip Code:48730-0231
Mailing Address - Country:US
Mailing Address - Phone:989-984-0929
Mailing Address - Fax:
Practice Address - Street 1:621 E LAKE ST
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9213
Practice Address - Country:US
Practice Address - Phone:989-984-0929
Practice Address - Fax:989-984-0931
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003215152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T96817Medicare UPIN