Provider Demographics
NPI:1720068984
Name:HOMESLEY, SUSAN DARNELL (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:DARNELL
Last Name:HOMESLEY
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 1:1516 MAIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-5242
Mailing Address - Country:US
Mailing Address - Phone:760-789-0950
Mailing Address - Fax:760-789-6057
Practice Address - Street 1:1516 MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-5242
Practice Address - Country:US
Practice Address - Phone:760-789-0950
Practice Address - Fax:760-789-6057
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-21
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP6693T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0066930Medicaid
CAOP6693Medicare ID - Type Unspecified
CASD0066930Medicaid