Provider Demographics
NPI:1821136102
Name:BELMONTE, SUSANA M (OD)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:M
Last Name:BELMONTE
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 1:122 41ST ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-2010
Mailing Address - Country:US
Mailing Address - Phone:916-455-5892
Mailing Address - Fax:
Practice Address - Street 1:2101 STONE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-4054
Practice Address - Country:US
Practice Address - Phone:916-372-3090
Practice Address - Fax:916-372-8055
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11561T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD001530Medicaid
CAGSD001530Medicaid
CAU86754Medicare UPIN