Provider Demographics
NPI:1629106729
Name:EVANS, SUSAN (OD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:EVANS
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 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:93 EVERGREEN WAY
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-6975
Practice Address - Country:US
Practice Address - Phone:860-826-4460
Practice Address - Fax:860-826-4436
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002478152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004188847Medicaid
CT1255448155OtherGHMC GROUP MEDICAID ID
CTCT2478OtherEYE MED VISION CARE
CT090002478CT04OtherBCBS & BCFP PROVIDER ID
CT102478OtherCONNECTICARE
CT1255448155OtherGHMC GROUP NPI
CT2V9149OtherHEALTH NET
CT932470OtherBLOCK VISION
CTU71030Medicare UPIN