Provider Demographics
NPI:1265559413
Name:PUTNAM, SUE RISTOW (OD)
Entity type:Individual
Prefix:DR
First Name:SUE
Middle Name:RISTOW
Last Name:PUTNAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SUE
Other - Middle Name:ANN
Other - Last Name:RISTOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:64 CALISTOGA CT
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-3004
Mailing Address - Country:US
Mailing Address - Phone:925-837-7304
Mailing Address - Fax:
Practice Address - Street 1:175 MARKETPLACE
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583
Practice Address - Country:US
Practice Address - Phone:925-275-0202
Practice Address - Fax:925-275-0447
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9770152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU65309Medicare UPIN