Provider Demographics
NPI:1760404602
Name:BUENSUCESO, FREDERICK CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:CHARLES
Last Name:BUENSUCESO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18277 W ESTES WAY
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-9636
Mailing Address - Country:US
Mailing Address - Phone:623-980-5496
Mailing Address - Fax:
Practice Address - Street 1:500 N ESTRELLA PKWY
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-4135
Practice Address - Country:US
Practice Address - Phone:623-980-5496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1352152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ144646Medicare PIN
AZZ144644Medicare PIN
AZZ144645Medicare PIN