Provider Demographics
NPI:1750581328
Name:TSENG, SUSAN PARK (OD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:PARK
Last Name:TSENG
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 1:9928 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1831
Mailing Address - Country:US
Mailing Address - Phone:773-303-8279
Mailing Address - Fax:
Practice Address - Street 1:9928 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1831
Practice Address - Country:US
Practice Address - Phone:773-303-8279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.009987152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009987Medicaid
IL046009987Medicaid