Provider Demographics
NPI:1609990522
Name:GRADY, SUSAN MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:GRADY
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 1:7900 SHELBYVILLE RD
Mailing Address - Street 2:STE. A15
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5451
Mailing Address - Country:US
Mailing Address - Phone:502-327-8568
Mailing Address - Fax:502-327-0613
Practice Address - Street 1:7900 SHELBYVILLE RD
Practice Address - Street 2:STE. A15
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5451
Practice Address - Country:US
Practice Address - Phone:502-327-8568
Practice Address - Fax:502-327-0613
Is Sole Proprietor?:No
Enumeration Date:2007-03-17
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1277DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00805798OtherRR MEDICARE
KY77012771Medicaid
KYP00805798OtherRR MEDICARE