Provider Demographics
NPI:1740267970
Name:DAVIS, SUSAN ELIZABETH (OD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:DAVIS
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:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IA
Mailing Address - Zip Code:52301-0204
Mailing Address - Country:US
Mailing Address - Phone:319-642-3311
Mailing Address - Fax:319-642-7111
Practice Address - Street 1:224 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IA
Practice Address - Zip Code:52301-1511
Practice Address - Country:US
Practice Address - Phone:319-642-3311
Practice Address - Fax:319-642-7111
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1641152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0145813Medicaid
IAT00883Medicare UPIN
IA14581Medicare ID - Type Unspecified
IA0230100001Medicare NSC