Provider Demographics
NPI:1760445449
Name:DISARIO, SUSAN T (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:T
Last Name:DISARIO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:T
Other - Last Name:DISARIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 102635
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2635
Mailing Address - Country:US
Mailing Address - Phone:912-354-4800
Mailing Address - Fax:912-629-5821
Practice Address - Street 1:4 OKATIE CTR BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29909-7529
Practice Address - Country:US
Practice Address - Phone:843-705-3333
Practice Address - Fax:843-705-3334
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1048152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9143OtherMEDICARE GROUP
SCD10487Medicaid
SC1760445449OtherMEDICARE RAILROAD
SCDA9642Medicaid
GA0412940007Medicare NSC
GA0412940004Medicare NSC
GA0412940002Medicare NSC
GA0412940001Medicare NSC
SCU548389143Medicare PIN
SC9143OtherMEDICARE GROUP
SCP00407664Medicare PIN
SCU548385109Medicare PIN