Provider Demographics
NPI:1700857281
Name:EGGEBRECHT, SUSAN LYNN (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:EGGEBRECHT
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 1:7750 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:US
Mailing Address - Phone:260-459-9595
Mailing Address - Fax:260-459-9494
Practice Address - Street 1:7750 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-459-9595
Practice Address - Fax:260-459-9494
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002378A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100464730Medicaid
T93040Medicare UPIN
IN100464730Medicaid