Provider Demographics
NPI:1639380017
Name:PENELOPE S. SUTER, O.D., AN OPTOMETRIC PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PENELOPE S. SUTER, O.D., AN OPTOMETRIC PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PENELOPE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SUTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:661-869-2010
Mailing Address - Street 1:5300 CALIFORNIA AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-1642
Mailing Address - Country:US
Mailing Address - Phone:661-869-2010
Mailing Address - Fax:661-869-2708
Practice Address - Street 1:5300 CALIFORNIA AVE STE 210
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309
Practice Address - Country:US
Practice Address - Phone:661-869-2010
Practice Address - Fax:661-869-2708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA08128T152W00000X
CA01828T152WV0400X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0081280Medicaid
CAGSD001690Medicaid
CAZZZ26807ZMedicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
CASD0081280Medicaid