Provider Demographics
NPI:1518918184
Name:PIETZ, SUSAN JO (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JO
Last Name:PIETZ
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 1:112 22ND AVE S
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2600
Mailing Address - Country:US
Mailing Address - Phone:605-882-1368
Mailing Address - Fax:
Practice Address - Street 1:26 5TH ST NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-3711
Practice Address - Country:US
Practice Address - Phone:605-882-2220
Practice Address - Fax:605-882-5675
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD597152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist