Provider Demographics
NPI:1659427102
Name:GOODE, SUSAN MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:GOODE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:LENTZ
Other - Last Name:GOODE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:14413 ILLINOIS RD
Mailing Address - Street 2:STE. C
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-9714
Mailing Address - Country:US
Mailing Address - Phone:260-616-0184
Mailing Address - Fax:855-271-9517
Practice Address - Street 1:14413 ILLINOIS RD
Practice Address - Street 2:STE. C
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-9714
Practice Address - Country:US
Practice Address - Phone:260-616-0184
Practice Address - Fax:855-271-9517
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003062A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist