Provider Demographics
NPI:1952447468
Name:NELSON, SUSAN M (LDO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:NELSON
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 PIO NONO AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206-3027
Mailing Address - Country:US
Mailing Address - Phone:478-781-2159
Mailing Address - Fax:478-746-9865
Practice Address - Street 1:236 TOM HILL SR BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1815
Practice Address - Country:US
Practice Address - Phone:478-471-7686
Practice Address - Fax:478-746-9865
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO001396156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician