Provider Demographics
NPI:1598889727
Name:SUSON OPTICAL CORPORATION
Entity Type:Organization
Organization Name:SUSON OPTICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-475-5550
Mailing Address - Street 1:2300 N MAYFAIR RD
Mailing Address - Street 2:SUITE 1101
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1505
Mailing Address - Country:US
Mailing Address - Phone:414-443-5289
Mailing Address - Fax:414-475-5550
Practice Address - Street 1:2300 N MAYFAIR RD
Practice Address - Street 2:SUITE 1101
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1505
Practice Address - Country:US
Practice Address - Phone:414-443-5289
Practice Address - Fax:414-475-5550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32237800Medicaid
WI38530200Medicaid
WI30936300Medicaid
WI32169600Medicaid
WIT83421Medicare UPIN
WIB56989Medicare UPIN
WI32237800Medicaid
WI000173555Medicare ID - Type Unspecified
WI38530200Medicaid
WI000673555Medicare ID - Type Unspecified
WI000373555Medicare ID - Type Unspecified
WI32169600Medicaid
WI4111200001Medicare NSC