Provider Demographics
NPI:1972667764
Name:MILLER, SUSAN K (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:MILLER
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 1:1468 JULIE CT
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-9582
Mailing Address - Country:US
Mailing Address - Phone:616-667-1853
Mailing Address - Fax:
Practice Address - Street 1:3700 RIVERTOWN PKWY SW
Practice Address - Street 2:SPACE 2112 RIVERTOWN CROSSINGS
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-3085
Practice Address - Country:US
Practice Address - Phone:616-249-7362
Practice Address - Fax:616-249-8097
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003738152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI158137Medicare UPIN
MIN26930149Medicare PIN