Provider Demographics
NPI:1972531051
Name:ZACATELCO, SUSAN C (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:C
Last Name:ZACATELCO
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 1:420 N JAMES RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-1834
Mailing Address - Country:US
Mailing Address - Phone:614-257-5200
Mailing Address - Fax:
Practice Address - Street 1:420 N JAMES RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-1834
Practice Address - Country:US
Practice Address - Phone:614-257-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5518T2430152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11506175OtherCAQH
ZA4179891Medicare ID - Type Unspecified
11506175OtherCAQH