Provider Demographics
NPI:1013916949
Name:MONAHAN, SUSAN ROST (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ROST
Last Name:MONAHAN
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 1:150 PROFESSIONAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-7232
Mailing Address - Country:US
Mailing Address - Phone:904-285-8448
Mailing Address - Fax:904-285-3410
Practice Address - Street 1:150 PROFESSIONAL DR STE 300
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-7232
Practice Address - Country:US
Practice Address - Phone:904-285-8448
Practice Address - Fax:904-285-3410
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4106152W00000X
FLOPC 4616152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA336271Medicaid
MA336271Medicaid
MAW17309Medicare ID - Type Unspecified