Provider Demographics
NPI:1588669220
Name:DANBERG, SUSAN C (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:C
Last Name:DANBERG
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 1:212 NEW LONDON TPKE
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033
Mailing Address - Country:US
Mailing Address - Phone:860-657-9189
Mailing Address - Fax:860-657-2504
Practice Address - Street 1:212 NEW LONDON TPKE
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033
Practice Address - Country:US
Practice Address - Phone:860-657-9189
Practice Address - Fax:860-657-2504
Is Sole Proprietor?:No
Enumeration Date:2005-06-18
Last Update Date:2007-10-05
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2007-10-05
Provider Licenses
StateLicense IDTaxonomies
CT1078152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT22775Medicare UPINUPIN