Provider Demographics
NPI:1700092350
Name:SULLENBERGER, SUSAN SIMPSON (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:SIMPSON
Last Name:SULLENBERGER
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 1:1699 N WOODLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-1803
Mailing Address - Country:US
Mailing Address - Phone:386-734-2240
Mailing Address - Fax:386-734-2240
Practice Address - Street 1:1699 N WOODLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-1803
Practice Address - Country:US
Practice Address - Phone:386-734-2240
Practice Address - Fax:386-734-2240
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 0003530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2083ZMedicare ID - Type Unspecified