Provider Demographics
NPI:1619046372
Name:GORNY, SUSAN MARIE (OD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:GORNY
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 1:2217 N 30TH ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98403-3320
Mailing Address - Country:US
Mailing Address - Phone:253-627-2818
Mailing Address - Fax:253-627-1901
Practice Address - Street 1:2217 N 30TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98403-3320
Practice Address - Country:US
Practice Address - Phone:253-627-2818
Practice Address - Fax:253-627-1901
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL3475TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1014601Medicaid
WA8858928Medicare PIN
WA1014601Medicaid
WA8885125Medicare PIN