Provider Demographics
NPI:1518096460
Name:BECK, SUSAN LA GRECA (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LA GRECA
Last Name:BECK
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 1:3920 BEE RIDGE RD
Mailing Address - Street 2:BLDG. A- STE. A
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-1207
Mailing Address - Country:US
Mailing Address - Phone:941-923-3411
Mailing Address - Fax:
Practice Address - Street 1:3920 BEE RIDGE RD
Practice Address - Street 2:BLDG. A STE. A
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-1207
Practice Address - Country:US
Practice Address - Phone:941-923-3411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4254152W00000X
DCOP764152W00000X
VA0618001274152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621330800Medicaid
FL621330800Medicaid