Provider Demographics
NPI:1912996711
Name:CUNNINGHAM, SUSAN JEAN (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEAN
Last Name:CUNNINGHAM
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 1:1416 ELM ST
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-2202
Mailing Address - Country:US
Mailing Address - Phone:510-323-3967
Mailing Address - Fax:
Practice Address - Street 1:901 E ST
Practice Address - Street 2:STE 285
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2850
Practice Address - Country:US
Practice Address - Phone:415-454-5565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 12288T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist