Provider Demographics
NPI:1891842464
Name:PENNER, SUSAN M (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:PENNER
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 1:134 E BLACKHAWK DR
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:IL
Mailing Address - Zip Code:61010-8610
Mailing Address - Country:US
Mailing Address - Phone:815-234-2020
Mailing Address - Fax:815-234-7070
Practice Address - Street 1:134 E BLACKHAWK DR
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:IL
Practice Address - Zip Code:61010
Practice Address - Country:US
Practice Address - Phone:815-234-2020
Practice Address - Fax:815-234-7070
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008009152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL08182OtherPIN
IL046-008009OtherOPTOMETRY LICENSE
IL4515286OtherBLUE CROSS BLUE SHIELD
IL7184011OtherBLUE CROSS BLUE SHIELD
ILCL7273OtherRAILROAD MEDICARE GROUP
IL410033446OtherRAILROAD MEDICARE
IL410033446OtherRAILROAD MEDICARE
ILL08182OtherPIN
IL7184011OtherBLUE CROSS BLUE SHIELD
IL410033446OtherRAILROAD MEDICARE
ILCL7273OtherRAILROAD MEDICARE GROUP
IL0253870002Medicare NSC