Provider Demographics
NPI:1588651913
Name:PREWANDOWSKI, SUSAN P (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:PREWANDOWSKI
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 1:64 WINTHROP ST
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-4242
Mailing Address - Country:US
Mailing Address - Phone:508-823-5536
Mailing Address - Fax:508-880-3798
Practice Address - Street 1:64 WINTHROP ST
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-4242
Practice Address - Country:US
Practice Address - Phone:508-823-5536
Practice Address - Fax:508-880-3798
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3451152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0155691Medicaid
MAB02084Medicare PIN
MA45245802Medicare PIN
MAU25124Medicare UPIN
MA410023697Medicare PIN