Provider Demographics
NPI:1184617680
Name:KEGARISE, SUSAN N (OD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:N
Last Name:KEGARISE
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 1:524B DONELSON PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37214-3729
Mailing Address - Country:US
Mailing Address - Phone:615-889-0147
Mailing Address - Fax:615-889-2700
Practice Address - Street 1:524B DONELSON PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37214-3729
Practice Address - Country:US
Practice Address - Phone:615-889-0147
Practice Address - Fax:615-889-2700
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1459152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN62-1827648OtherTAX ID
TN62-1827648OtherTAX ID
TNMK0119405OtherDEA
TN1020400001Medicare NSC
TN3599077Medicare ID - Type Unspecified