Provider Demographics
NPI:1255371407
Name:LATHROP, SUSAN GROMACKI (OD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:GROMACKI
Last Name:LATHROP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4868 GREEN BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:MD
Mailing Address - Zip Code:21036-1211
Mailing Address - Country:US
Mailing Address - Phone:410-531-6967
Mailing Address - Fax:
Practice Address - Street 1:8115 MAPLE LAWN BLVD.
Practice Address - Street 2:SUITE 135
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2681
Practice Address - Country:US
Practice Address - Phone:301-490-3036
Practice Address - Fax:443-288-4694
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003970152W00000X
MDTA2282152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist