Provider Demographics
NPI:1851446751
Name:SUSEL, ROSE (OD OPTOMETRIST)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:SUSEL
Suffix:
Gender:F
Credentials:OD OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 HOWARD GROVE RD
Mailing Address - Street 2:
Mailing Address - City:DAVIDSONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21035
Mailing Address - Country:US
Mailing Address - Phone:410-533-7763
Mailing Address - Fax:410-956-2594
Practice Address - Street 1:2510 HOWARD GROVE RD
Practice Address - Street 2:
Practice Address - City:DAVIDSONVILLE
Practice Address - State:MD
Practice Address - Zip Code:21035
Practice Address - Country:US
Practice Address - Phone:410-533-7763
Practice Address - Fax:410-956-2594
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2010-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOP661152W00000X
VA0601001725152W00000X
MDTA1082152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC018590600Medicaid
MD081778300Medicaid
U26561Medicare UPIN
MD566RMedicare ID - Type Unspecified
MD081778300Medicaid