Provider Demographics
NPI:1790901189
Name:VASQUEZ, SUSANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSANNE
Middle Name:
Last Name:VASQUEZ
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 1:23 FENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-1029
Mailing Address - Country:US
Mailing Address - Phone:914-834-2089
Mailing Address - Fax:
Practice Address - Street 1:23 FENBROOK DR
Practice Address - Street 2:
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-1029
Practice Address - Country:US
Practice Address - Phone:914-834-2089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTOO5675-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYTOO5675-1OtherLICENSE NUMBER