Provider Demographics
NPI:1013051358
Name:ROSS, SUSAN (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:DIANA
Other - Last Name:GUZICK-ROSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:29665 CEDAR RD
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-4411
Mailing Address - Country:US
Mailing Address - Phone:216-521-2020
Mailing Address - Fax:
Practice Address - Street 1:18216 SLOANE AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3110
Practice Address - Country:US
Practice Address - Phone:216-521-2020
Practice Address - Fax:216-521-6088
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3491 T1509152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHU76945Medicare UPIN
OHGU0882911Medicare PIN