Provider Demographics
NPI:1881736320
Name:HORIUCHI, SUSAN HARTLEY (OD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:HARTLEY
Last Name:HORIUCHI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:HARTLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:330 PARK AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2352
Mailing Address - Country:US
Mailing Address - Phone:949-494-2546
Mailing Address - Fax:949-497-0010
Practice Address - Street 1:330 PARK AVE STE 4
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2352
Practice Address - Country:US
Practice Address - Phone:949-494-2546
Practice Address - Fax:949-497-0010
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7484T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0074840Medicaid
CA0180480001OtherCMS
CAOP7484 CAOtherMEDICARE
CA0180480001OtherDMERC REGION D
CA0182880001OtherMEDICARE NSC
CA0180480001OtherDMERC REGION D
CA0180480001OtherCMS
CASD0074840Medicaid