Provider Demographics
NPI:1700855327
Name:KOVACICH, SUSAN K (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:K
Last Name:KOVACICH
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 1:800 E ATWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-3635
Mailing Address - Country:US
Mailing Address - Phone:812-855-4447
Mailing Address - Fax:
Practice Address - Street 1:800 E ATWATER AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3635
Practice Address - Country:US
Practice Address - Phone:812-855-4447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002933152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200192790Medicaid
IN544150VVMedicare PIN
IN200192790Medicaid
U13848Medicare UPIN