Provider Demographics
NPI:1376681510
Name:SUSAN J. DEVINE OD, LLC
Entity type:Organization
Organization Name:SUSAN J. DEVINE OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-623-8013
Mailing Address - Street 1:PO BOX 438
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06088-0438
Mailing Address - Country:US
Mailing Address - Phone:860-623-8013
Mailing Address - Fax:860-627-6433
Practice Address - Street 1:44 PROSPECT HILL RD
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06088-9501
Practice Address - Country:US
Practice Address - Phone:860-623-8013
Practice Address - Fax:860-627-6433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02888Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER