Provider Demographics
NPI:1629255344
Name:ORVIS, SUSAN L (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:ORVIS
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:W63 N543 B HANOVER AVE.
Mailing Address - Street 2:P.O. BOX 826
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-0826
Mailing Address - Country:US
Mailing Address - Phone:262-377-3937
Mailing Address - Fax:262-377-3948
Practice Address - Street 1:W63 N543 B HANOVER AVE.
Practice Address - Street 2:
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-0826
Practice Address - Country:US
Practice Address - Phone:262-377-3937
Practice Address - Fax:262-377-3948
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2522-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU41198Medicare UPIN