Provider Demographics
NPI:1821109703
Name:O'SHEA, SUSAN MARIANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIANNE
Last Name:O'SHEA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:MARIANNE
Other - Last Name:FOLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1341 BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3909
Mailing Address - Country:US
Mailing Address - Phone:508-661-9532
Mailing Address - Fax:
Practice Address - Street 1:1341 BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3909
Practice Address - Country:US
Practice Address - Phone:508-661-9532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4515152WP0200X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110073128Medicaid
MAW17594Medicare ID - Type Unspecified